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Slide 1 - Virginia Health Information Management Association ...

  1. 1. MS-DRGs – The First Six Months Update April 2008 Virginia HIMA Annual Convention Melinda S. Stegman, MBA, CCS
  2. 2. Agenda – MS-DRGs <ul><li>Brief overview </li></ul><ul><li>New concepts introduced with MS-DRGs </li></ul><ul><ul><li>Conditional MCCs </li></ul></ul><ul><ul><li>MCCs and CCs excluded by DRG definition </li></ul></ul><ul><ul><li>Procedure Proxies </li></ul></ul><ul><li>Undocumented changes, inconsistencies and what really happened (MDCs 03 and 09) </li></ul><ul><li>Relative Weight issues </li></ul><ul><li>Potential overcoding (maximizing): Beware </li></ul><ul><li>MS-DRGs and RAC Issues </li></ul><ul><li>Conclusions </li></ul>
  3. 3. MS-DRG Basics <ul><li>Officially named MS-DRGs (Medicare Severity) </li></ul><ul><li>Built on CMS DRGs (similar subgroups) </li></ul><ul><li>745 final DRGs numbered from 001 to 999 </li></ul><ul><li>Explanation of variance in consumed hospital resources increased over previous DRGs by 9.41% </li></ul><ul><li>Major overhaul of previous CCs </li></ul><ul><li>1, 2 and 3-way splits based on CC or MCC </li></ul><ul><ul><li>With MCC, with CC or without CC/MCC (e.g. concussion, major chest procedures) </li></ul></ul><ul><ul><li>With CC/MCC or without CC/MCC (e.g. bronchitis or asthma) </li></ul></ul><ul><ul><li>With MCC or without MCC (e.g. seizures, headaches) </li></ul></ul><ul><ul><li>No splits (e.g. angina pectoris, chest pain) </li></ul></ul>
  4. 4. Conditional MCCs <ul><li>Certain MCCs are excluded from list unless the patient is discharged alive </li></ul><ul><ul><li>427.41( ventricular fibrillation ) </li></ul></ul><ul><ul><li>427.5 ( cardiac arrest ) </li></ul></ul><ul><ul><li>785.51 ( cardiogenic shock ) </li></ul></ul><ul><ul><li>785.59 ( other shock without mention of trauma ) </li></ul></ul><ul><ul><li>799.1 ( respiratory arrest ) </li></ul></ul><ul><li>If the patient expires, the conditions above are considered non-CCs </li></ul>
  5. 5. MCCs and CCs Excluded by DRG Definition <ul><li>Many MS DRGs use secondary diagnoses as part of the DRG definition </li></ul><ul><ul><li>E.g.: MS DRG 280/281/282 AMI, Discharged Alive – Must have principal dx in MDC 05, any dx of AMI Initial Episode </li></ul></ul><ul><li>If a diagnoses is part of the definition of a DRG it is excluded from being a CC/MCC by the DRG (even if the diagnosis is not used in DRG assignment) </li></ul><ul><ul><li>E.g.: 410.01, 410.11, 410.21, 410.31, 410.41, 410.51, 410.61, 410.71, 410.81, 410.91 are excluded from being MCC in MS DRG 280, even if more than one is present. </li></ul></ul>
  6. 6. MCCs and CCs Excluded by DRG Definition Breast Malignancy (198.2, 198.81) 582 – Mastectomy for Malignancy Acute Leukemia (204.00, 204.01, 205.00, 205.01, 206.00, 206.01, 207.00, 207.01, 208.00, 208.01) 837, 838 – Chemotherapy with Acute Leukemia as SDx or with High Dose Chemotherapy Agent (only cases with acute Leukemia as SDx) Full Thickness Burn (941-949) 928 – Full Thickness Burn w Skin Graft or Inhalation Injection Significant Trauma (Many Dxs) 957, 958 – Other O.R. Procedures for Multiple Significant Trauma Significant Trauma (Many Dxs) 963, 964 – Other Multiple Significant Trauma HIV (042) and HIV Related Conditions (Many Dxs) 974, 975 – HIV with Major Related Condition AMIs (410.01, 410.11, 410.21, 410.31, 410.41, 410.51, 410.61, 410.71, 410.81, 410.91) 283, 284 – AMI, Expired AMIs (410.01, 410.11, 410.21, 410.31, 410.41, 410.51, 410.61, 410.71, 410.81, 410.91) 280, 281 – AMI, Discharged Alive Traumatic stupor and Coma Dxs (800-804, 851-854) 082, 083 – Traumatic Stupor and Coma, Coma > 1 hour Excluded CC/MCC Dxs MS-DRG
  7. 7. MCC/CC Capture Rates <ul><li>CMS has estimated that MCC/CC Capture Rates would decrease to approximately 40% nationally. </li></ul><ul><li>Does your facility calculate MCC/CC Capture Rates on a routine on-going basis? </li></ul>
  8. 8. Procedures Used as “Proxy” for MCC/CCs <ul><li>DRG 024 Craniotomy w major device … w/o MCC ==> DRG 023 Craniotomy w major device… w MCC or chemo implant with 00.10 (implantation of chemotherapeutic agent) </li></ul><ul><li>DRG 030 Spinal procedures w/o CC/MCC ==> DRG 029 Spinal procedures w CC/MCC or spinal neurostimulators with combination of 03.93 and 86.94, 86.95 or 86.97 </li></ul><ul><li>DRG 042 Peripheral & cranial nerve proc… w/o CC/MCC ==> DRG 041 Peripheral & cranial nerve proc… w CC or peripheral neurostimulators with a combination of 04.92 and 86.94, 86.95, 86.97 or 86.98 DRG 040 Peripheral & cranial nerve proc… w MCC </li></ul><ul><li>DRG 130 Major head & neck procedures w/o MCC ==> DRG 129 Major head & neck procedures w MCC or major device with 20.96 or 20.97 or 20.98 (cochlear implants) </li></ul>
  9. 9. Procedures Used as “Proxy” for MCC/CCs <ul><li>DRG 238 Major cardiovascular procedures w/o MCC ==> DRG 237 Major cardiovascular procedures w MCC or thoracic aortic aneurysm repair with 39.73 (Endovascular implantation of graft in thoracic aorta) </li></ul><ul><li>DRG 247 Percutaneous CV procedure w drug-eluting stent w/o MCC ==> DRG 246 Percutaneous CV procedure w drug-eluting stent w MCC or 4+ vessels/stents with combination procedures (00.66 and 36.07) with 00.43 or 00.48 </li></ul><ul><li>DRG 249 Percutaneous CV procedure w non-drug-eluting stent w/o MCC ==> DRG 248 Percutaneous CV procedure w non-drug-eluting stent w MCC or 4+ vessels/stents with combination procedures (00.66 and 36.06) with 00.43 or 00.48 </li></ul>
  10. 10. Procedures Used as “Proxy” for MCC/CCs <ul><li>DRG 491 Back & neck procedure exc spinal fusion w/o CC/MCC DRG 490 Back & neck procedure exc spinal fusion w CC/MCC or disc device/neurostimulator with 84.59, 84.62, 84.65, 84.80, 84.82, 84.84 OR combination 03.93 and 86.94, 86.95, 86.97 or 86.98 </li></ul><ul><li>DRG 839 Chemo w acute leukemia w/o CC/MCC ==> DRG 838 Chemo w acute leukemia w CC or high dose chemo agent with 00.15 (hi-dose infusion of interleukin-2) DRG 837 Chemo w acute leukemia w MCC or high dose chemo agent with 00.15 (hi-dose infusion of interleukin-2) </li></ul><ul><li>DRG 006 Liver transplant w/o MCC ==> DRG 005 Liver transplant w MCC or intestinal transplant with 46.97 (Transplant of intestine) </li></ul>
  11. 11. Undocumented Changes & Inconsistencies by CMS <ul><li>Inconsistencies in CMS documentation </li></ul><ul><ul><li>Table F (Final Rule; Federal Register; Vol. 72, No. 162, August 22, 2007, page 47156) </li></ul></ul><ul><ul><li>CMS-DRG to MS-DRG crosswalk (both in Proposed Rule and Final Rule) </li></ul></ul>
  12. 12. CMS DRG Model, MDC 9 - Diseases & Disorders Of The Skin, Subcutaneous Tissue & Breast (CMS-DRGs) Yes Skin Graft and Debridement 263 268 267 Perianal and Pilonidal Cyst Procedures Plastic Procedures No O.R. Procedure 2 Yes No Surgical Partitioning PDX Skin Ulcer or Cellulitis CC Yes No 264 CC 265 No 266 Yes 1
  13. 13. CMS DRG Model, MDC 9 - Diseases & Disorders Of The Skin, Subcutaneous Tissue & Breast (CMS-DRGs) 257 258 259 260 Total Mastectomy Mastectomy and Any DX of Breast Malignancy Yes 1 Yes No CC Subtotal Mastectomy Yes No CC 261 262 269 270 No Breast without Biopsy and Local Excision Breast Biopsy and Local Excision Yes No CC Other Skin, Subcutaneous Tissue and Breast Procedures Unrelated OR Logic
  14. 14. MDC – 09 Surgical Hierarchy Under MS-DRGs
  15. 15. MDC – 09 Surgical Hierarchy Under MS-DRGs
  16. 16. Unintended Consequences <ul><li>Procedures in V24 DRG 269, 270 have leapfrogged in the surgical hierarchy procedures in V24 DRGs 257-260 </li></ul><ul><li>This means cases with the following procedures will take precedence OVER mastectomies: </li></ul><ul><ul><li>86.09 – Skin & Subq Incision NEC </li></ul></ul><ul><ul><li>86.3 – Other Local Destruc Skin </li></ul></ul>
  17. 17. MDC 03 - What was Documented <ul><li>The Final Rule: </li></ul>
  18. 18. MDC 03 - What was Documented - Inconsistencies <ul><li>CMS Crosswalk from CMS-DRGs to MS-DRGs: </li></ul>            063 062 061 060 059 058 057 056 Other ear, nose, mouth & throat O.R. procedures w/o CC/MCC 134 055 Other ear, nose, mouth & throat O.R. procedures w CC/MCC 133 S 03 052             Cranial/facial procedures w/o CC/MCC 132 Cranial/facial procedures w CC/MCC 131 S 03             Comments MS-DRG Descriptions MS v25 medsurg mdc CMS V24
  19. 19. MDC 03 – What happened 049 - Major Head & Neck Procedures 129/130 - Major Head & Neck Procedures 061/062 – Myringotomy w Tube Insertion 131/132 – Cranial/Facial Bone Procedures 053/054 – Sinus & Mastoid Procedures 133/134 – Other Ear, Nose, Mouth & Throat Procedures 168/169 – Mouth Procedures 057/058 – T&A Procedures Except T&A Only (T&A Procs) 057/058 – T&A Procedures Except T&A Only (Other T&A Procs) 052 – Cleft Lip & Palate Repair 056 – Rhinoplasty 050 – Sialoadenectomy 051 – Salivary Gland Procedures Except Sialoadenectomy 055 – Misc Ear, Nose, Throat & Mouth Procedures 059/060 – T&A Only 063 – Other Ear, Nose, Throat & Mouth 135/136 – Sinus & Mastoid Procedures 137/138 – Mouth Procedures 139 – Salivary Gland Procedures
  20. 20. MDC 03 – What happened 049 - Major Head & Neck Procedures 129/130 - Major Head & Neck Procedures 061/062 – Myringotomy w Tube Insertion 131/132 – Cranial/Facial Bone Procedures 053/054 – Sinus & Mastoid Procedures 133/134 – Other Ear, Nose, Mouth & Throat Procedures 168/169 – Mouth Procedures 057/058 – T&A Procedures Except T&A Only (T&A Procs) 057/058 – T&A Procedures Except T&A Only (Other T&A Procs) 052 – Cleft Lip & Palate Repair 056 – Rhinoplasty 050 – Sialoadenectomy 051 – Salivary Gland Procedures Except Sialoadenectomy 055 – Misc Ear, Nose, Throat & Mouth Procedures 059/060 – T&A Only 063 – Other Ear, Nose, Throat & Mouth 135/136 – Sinus & Mastoid Procedures 137/138 – Mouth Procedures 139 – Salivary Gland Procedures
  21. 21. MDC 03 – What happened 049 - Major Head & Neck Procedures 129/130 - Major Head & Neck Procedures 061/062 – Myringotomy w Tube Insertion 131/132 – Cranial/Facial Bone Procedures 053/054 – Sinus & Mastoid Procedures 133/134 – Other Ear, Nose, Mouth & Throat Procedures 168/169 – Mouth Procedures 057/058 – T&A Procedures Except T&A Only (T&A Procs) 057/058 – T&A Procedures Except T&A Only (Other T&A Procs) 052 – Cleft Lip & Palate Repair 056 – Rhinoplasty 050 – Sialoadenectomy 051 – Salivary Gland Procedures Except Sialoadenectomy 055 – Misc Ear, Nose, Throat & Mouth Procedures 059/060 – T&A Only 063 – Other Ear, Nose, Throat & Mouth 135/136 – Sinus & Mastoid Procedures 137/138 – Mouth Procedures 139 – Salivary Gland Procedures
  22. 22. MDC 03 – What happened 049 - Major Head & Neck Procedures 129/130 - Major Head & Neck Procedures 061/062 – Myringotomy w Tube Insertion 131/132 – Cranial/Facial Bone Procedures 053/054 – Sinus & Mastoid Procedures 133/134 – Other Ear, Nose, Mouth & Throat Procedures 168/169 – Mouth Procedures 057/058 – T&A Procedures Except T&A Only (T&A Procs) 057/058 – T&A Procedures Except T&A Only (Other T&A Procs) 052 – Cleft Lip & Palate Repair 056 – Rhinoplasty 050 – Sialoadenectomy 051 – Salivary Gland Procedures Except Sialoadenectomy 055 – Misc Ear, Nose, Throat & Mouth Procedures 059/060 – T&A Only 063 – Other Ear, Nose, Throat & Mouth 135/136 – Sinus & Mastoid Procedures 137/138 – Mouth Procedures 139 – Salivary Gland Procedures
  23. 23. MDC 03 – What happened 049 - Major Head & Neck Procedures 129/130 - Major Head & Neck Procedures 061/062 – Myringotomy w Tube Insertion 131/132 – Cranial/Facial Bone Procedures 053/054 – Sinus & Mastoid Procedures 133/134 – Other Ear, Nose, Mouth & Throat Procedures 168/169 – Mouth Procedures 057/058 – T&A Procedures Except T&A Only (T&A Procs) 057/058 – T&A Procedures Except T&A Only (Other T&A Procs) 052 – Cleft Lip & Palate Repair 056 – Rhinoplasty 050 – Sialoadenectomy 051 – Salivary Gland Procedures Except Sialoadenectomy 055 – Misc Ear, Nose, Throat & Mouth Procedures 059/060 – T&A Only 063 – Other Ear, Nose, Throat & Mouth 135/136 – Sinus & Mastoid Procedures 137/138 – Mouth Procedures 139 – Salivary Gland Procedures Non MDC 03 Procedures
  24. 24. MDC 03 – What happened <ul><li>Procedure Codes from V24 DRG 055 in MS DRG 131/132 </li></ul><ul><ul><li>21.4 – Resection of the Nose </li></ul></ul><ul><ul><li>21.72 – Open Resection of Nasal Fracture </li></ul></ul><ul><li>Procedure Codes from V24 DRG 063 in MS DRG 131/132 </li></ul><ul><ul><li>16.52 – Exenteration Orbit Therapeutic Removal Orbital Bone </li></ul></ul><ul><ul><li>16.98 - Other Operations on Orbit </li></ul></ul><ul><ul><li>76.01 – Sequestrectomy of Facial Bone wo Division </li></ul></ul><ul><ul><li>76.19 – Other Diagnostic Procedures on Facial Bones and Joints </li></ul></ul><ul><ul><li>76.2 – Local Excision or Destruction of Lesion of Facial Bone </li></ul></ul><ul><ul><li>76.39 – Partial Ostectomy of Other Facial Bone </li></ul></ul><ul><ul><li>76.43 – Other Reconstruction of Mandible </li></ul></ul><ul><ul><li>76.44 – Total Ostectomy of Other Facial Bone w Synchronous Reconstruction </li></ul></ul><ul><ul><li>76.45 – Other Total Ostectomy of Other Facial Bone </li></ul></ul><ul><ul><li>76.46 – Other Reconstruction of Other Facial Bone </li></ul></ul><ul><ul><li>76.61 – Closed Osteoplasty (Osteotomy) of Mandibular Ramus </li></ul></ul><ul><ul><li>76.62 – Open Osteoplasty (Osteotomy) of Mandibular Ramus </li></ul></ul><ul><ul><li>76.63 – Osteoplasty (Osteotomy) of Body of Mandible </li></ul></ul><ul><ul><li>76.64 – Other Orthognathic Surgery of Mandible </li></ul></ul>
  25. 25. MDC 03 – What happened <ul><li>Procedure Codes from V24 DRG 063 in MS DRG 131/132 (con’t) </li></ul><ul><ul><li>76.65 – Segmental Osteoplasty (Osteotomy) of Maxilla </li></ul></ul><ul><ul><li>76.66 – Total Osteoplasty (Osteotomy) of Maxilla </li></ul></ul><ul><ul><li>76.67 – Reduction Genioplasty </li></ul></ul><ul><ul><li>76.68 – Augmentation Genioplasty </li></ul></ul><ul><ul><li>76.69 – Other Facial Bone Repair </li></ul></ul><ul><ul><li>76.70 – Reduction of Facial Fracture, Not Otherwise Specified </li></ul></ul><ul><ul><li>76.72 – Open Reduction of Malar and Zygomatic Fracture </li></ul></ul><ul><ul><li>76.74 – Open Reduction of Maxillary Fracture </li></ul></ul><ul><ul><li>76.76 – Open Reduction of Mandibular Fracture </li></ul></ul><ul><ul><li>76.77 – Open Reduction of Alveolar Fracture </li></ul></ul><ul><ul><li>76.79 – Other Open Reduction of Facial Fracture </li></ul></ul><ul><ul><li>76.91 – Bone Graft to Facial Bone </li></ul></ul><ul><ul><li>76.92 – Insertion of Synthetic Implant in Facial Bone </li></ul></ul><ul><ul><li>76.94 – Open Reduction of Temporomandibular Dislocation </li></ul></ul><ul><ul><li>76.97 – Removal Internal Fixation Device Facial bone </li></ul></ul><ul><ul><li>76.99 – Other Operations on Facial Bones and Joints </li></ul></ul>
  26. 26. MDC 03 – What happened <ul><li>Non MDC 03 Procedure Codes from V24 in MS DRG 131/132 </li></ul><ul><ul><li>01.23 – Craniotomy and Craniectomy; Reopening of Craniotomy Site </li></ul></ul><ul><ul><li>01.24 – Other Craniotomy </li></ul></ul><ul><ul><li>01.25 – Other Craniectomy </li></ul></ul><ul><ul><li>01.6 – Excision of Lesion of Skull </li></ul></ul><ul><ul><li>02.01 – Opening of Cranial Suture </li></ul></ul><ul><ul><li>02.02 – Elevation of Skull Fracture Fragments </li></ul></ul><ul><ul><li>02.03 – Formation of Cranial Bone Flap </li></ul></ul><ul><ul><li>02.04 – Bone Graft to Skull </li></ul></ul><ul><ul><li>02.05 – Insertion of Skull Plate </li></ul></ul><ul><ul><li>02.06 – Cranial Osteoplasty </li></ul></ul><ul><ul><li>02.07 – Removal of Skull Plate </li></ul></ul><ul><ul><li>02.99 – Other Operations on Skull, Brain, and Cerebral Meninges; Other </li></ul></ul><ul><ul><li>16.01 – Orbitotomy with Bone Flap </li></ul></ul><ul><ul><li>16.02 – Orbitotomy with Insertion of Orbital Implant </li></ul></ul><ul><ul><li>16.09 – Other Orbitotomy </li></ul></ul><ul><ul><li>16.51 – Exenteration of Orbit with Removal of Adjacent Structures </li></ul></ul><ul><ul><li>16.59 – Other Exenteration of Orbit </li></ul></ul><ul><ul><li>16.63 – Revision of Enucleation Socket with Graft </li></ul></ul><ul><ul><li>16.64 – Other Revision of Enucleation Socket </li></ul></ul><ul><ul><li>16.89 – Other Repair of Injury of Eyeball or Orbit </li></ul></ul><ul><ul><li>16.92 – Excision of Lesion of Orbit </li></ul></ul>
  27. 27. Relative Weights are NOT Consistent <ul><li>DRGs based on medical knowledge should be higher in relative weight, are not necessarily: </li></ul><ul><ul><li>MS DRG 082 Traumatic Stupor and Coma, Coma > 1 hour with MCC has a weight of 1.6724 </li></ul></ul><ul><ul><li>MS DRG 085 Traumatic Stupor and Coma, Coma < 1 hour with MCC has a weight of 1.6946 </li></ul></ul><ul><ul><li>MS DRG 083 Traumatic Stupor and Coma, Coma > 1 hour with CC has a weight of 1.3328 </li></ul></ul><ul><ul><li>MS DRG 086 Traumatic Stupor and Coma, Coma < 1 hour with CC has a weight of 1.2337 </li></ul></ul><ul><ul><li>MS DRG 084 Traumatic Stupor and Coma, Coma > 1 hour without CC/MCC has a weight of 1.1106 </li></ul></ul><ul><ul><li>MS DRG 087 Traumatic Stupor and Coma, Coma < 1 hour without CC/MCC has a weight of 0.9235 </li></ul></ul>
  28. 28. Relative Weights are NOT Consistent <ul><li>Like conditions don’t necessarily correspond to similar change in weights </li></ul><ul><ul><li>MS DRG 716 has a higher weight than MS DRG 718 </li></ul></ul><ul><ul><ul><li>MS DRG 716 Other Male Rep. Sys. With PDX Malignancy without CC/MCC has a weight of 1.1310 </li></ul></ul></ul><ul><ul><ul><li>MS DRG 718 Other Male Rep. Sys. Without PDX Malignancy without CC/MCC has a weight of 1.0329 </li></ul></ul></ul><ul><ul><li>MS DRG 715 has a lower weight than MS DRG 717 </li></ul></ul><ul><ul><ul><li>MS DRG 715 Other Male Rep. Sys. With PDX Malignancy with CC/MCC has a weight of 1.5300 </li></ul></ul></ul><ul><ul><ul><li>MS DRG 717 Other Male Rep. Sys. Without PDX Malignancy with CC/MCC has a weight of 1.5653 </li></ul></ul></ul>
  29. 29. Potential Overcoding Examples
  30. 30. Potential Overcoding: Beware! <ul><li>Number 1 high-dollar overcoded DRG subgroup: </li></ul><ul><ul><li>DRG 981 Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC RW 4.5168 ($22,584) </li></ul></ul><ul><ul><li>DRG 982 Extensive O.R. Procedure Unrelated to Principal Diagnosis with CC RW 3.5417 ($17,709) </li></ul></ul><ul><ul><li>DRG 983 Extensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC RW 2.9737 ($14,869) </li></ul></ul><ul><li>Old DRG 468 FY07 RW 3.9880 ($19,940) </li></ul><ul><li>Issue: what is the definition of principal diagnosis? </li></ul><ul><li>Co-existing principal diagnoses: was the patient really admitted for the treatment of BOTH conditions? </li></ul>
  31. 31. Potential Overcoding: Beware! <ul><li>Sequencing issues: </li></ul><ul><ul><li>Example: a patient with long-standing COPD is admitted with acute exacerbation and superimposed pneumonia. The physician indicates that the exacerbation is likely due to the pneumonia. The patient is admitted and treated with IV antibiotics, steroids and nebulizers. </li></ul></ul><ul><ul><li>What is the principal diagnosis? </li></ul></ul>
  32. 32. Potential Overcoding: Beware! <ul><li>Prior to 10/1/07, sequencing pneumonia first was best financially. </li></ul><ul><li>Since MS-DRGs include subgroups for COPD, the highest weighted one (with MCC) carries a higher RW than the simple pneumonia DRG. </li></ul><ul><li>BUT…don’t forget the sequencing rules. The patient was really admitted for pneumonia, which caused the COPD exacerbation. </li></ul>For FY07 For FY07 DRG 088 RW 0.8878 ($4,439) DRG 089 RW 1.0376 ($5,188) MS-DRG 195 RW 0.8398 ($4,199) (with 496 as sdx) MS-DRG 194 RW 1.0235 ($5,118) (with 491.21 as sdx) Pneumonia MS-DRG 190 RW 1.1138 ($5,569) COPD
  33. 33. Potential Overcoding: Beware! <ul><li>Infectious Diseases </li></ul><ul><ul><li>Don’t infer that any positive culture means a systemic infection </li></ul></ul><ul><ul><ul><li>Contaminants (such as staph epidermis) </li></ul></ul></ul><ul><ul><ul><li>Localized superficial infections (such as oral thrush causing a positive yeast culture) </li></ul></ul></ul><ul><ul><ul><li>Look at the entire clinical picture </li></ul></ul></ul><ul><ul><ul><ul><li>Treatment options (extended IV antibiotics or anti-fungals) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Length of stay </li></ul></ul></ul></ul>
  34. 34. Potential Overcoding: Beware! <ul><li>Sepsis </li></ul><ul><ul><li>Do not code sepsis based on ONE progress note or other mention in the documentation; it may have been considered a “rule-out” condition. </li></ul></ul><ul><ul><li>“ Urosepsis” still codes to urinary tract infection </li></ul></ul><ul><ul><li>“ Line sepsis” </li></ul></ul><ul><ul><ul><li>Code 996.62 Infection/inflammatory reaction due to other vascular device, implant and graft should be PDX </li></ul></ul></ul><ul><ul><ul><li>See Coding Clinic , 2 nd Quarter 2004, page 16: </li></ul></ul></ul><ul><ul><ul><li>When a patient has sepsis due to the vascular catheter, code 996.62, Infection and inflammatory reaction due to other vascular catheter, should be the principal diagnosis, followed by the appropriate sepsis code, generally a code from category 038 and a code from subcategory 995.9. </li></ul></ul></ul>
  35. 35. Potential Overcoding: Beware! <ul><li>Malnutrition </li></ul><ul><ul><li>May be due to insufficient intake, increased loss, increased demand, or a condition that decreases the body’s ability to digest and absorb nutrients. </li></ul></ul><ul><ul><li>MCCs include: </li></ul></ul><ul><ul><ul><li>260 Kwashiorkor (not typically seen in U.S. hospitals) </li></ul></ul></ul><ul><ul><ul><li>261 Nutritional marasmus </li></ul></ul></ul><ul><ul><ul><li>262 Other severe, protein-calorie malnutrition </li></ul></ul></ul><ul><ul><li>CCs include: </li></ul></ul><ul><ul><ul><li>263.2 Arrested development following protein-calorie malnutrition </li></ul></ul></ul><ul><ul><ul><li>263.8 Other protein-calorie malnutrition </li></ul></ul></ul><ul><ul><ul><li>263.9 Unspecified protein-calorie malnutrition </li></ul></ul></ul>
  36. 36. Potential Overcoding: Beware! <ul><li>Malnutrition </li></ul><ul><ul><li>Do not assign these codes based on documentation of “unexpected weight loss” alone </li></ul></ul><ul><ul><li>Look for in patients with: </li></ul></ul><ul><ul><ul><li>Chronic conditions: short-gut syndrome, GI infectious processes, GI malignancies, malabsorption syndromes: (celiac disease, cystic fibrosis, pancreatic insufficiency, Crohn’s disease, pernicious anemia) </li></ul></ul></ul><ul><ul><ul><li>Acute conditions: severe burns, infection, surgery, trauma </li></ul></ul></ul><ul><ul><li>Measurable substantiation must be present in the record: </li></ul></ul><ul><ul><ul><li>Total protein (A/G Ratio) </li></ul></ul></ul><ul><ul><ul><li>Hemoglobin </li></ul></ul></ul><ul><ul><ul><li>Albumin </li></ul></ul></ul><ul><ul><ul><li>Vitamin deficiency </li></ul></ul></ul>
  37. 37. Potential Overcoding: Beware! <ul><li>Mechanical ventilation </li></ul><ul><ul><li>96.70 Continuous mechanical ventilation for unspec duration </li></ul></ul><ul><ul><li>96.71 Continuous mechanical ventilation for < 96 hours </li></ul></ul><ul><ul><li>96.72 Continuous mechanical ventilation for > 96 hours </li></ul></ul><ul><li>Do NOT assign these codes for: </li></ul><ul><ul><li>CPAP or BiPAP delivered through tracheostomy </li></ul></ul><ul><ul><ul><li>Forms of respiratory assistance </li></ul></ul></ul><ul><ul><ul><li>Augments the patient’s own breathing </li></ul></ul></ul><ul><li>Refer to Coding Clinic , 1 st Quarter 2008, pages 8-9 </li></ul><ul><li>Be sure to review your Ventilation forms in the record; ensure that CPAP & BiPAP are differentiated </li></ul>
  38. 38. Potential Overcoding: Beware! <ul><li>Mechanical ventilation </li></ul><ul><ul><li>High-dollar DRG risk area </li></ul></ul><ul><ul><li>All other medical MDC 4 DRGs have an average RW of 1.1255 ($5,628) </li></ul></ul><ul><ul><li>These DRGs are under scrutiny by RACs, other government auditors </li></ul></ul><ul><ul><li>All MS-DRGs 207 & 208 should be routinely reviewed internally </li></ul></ul>RW 5.1231 $25,616 RW 2.2463 $11,232 Codes: 96.72 > 96 hours Codes: 96.70 Unspec duration 96.71 < 96 hours MS-DRG 207 MS-DRG 208
  39. 39. Potential Overcoding: Beware! <ul><li>Coagulopathy </li></ul><ul><ul><li>PDX documented as “Coumadin-induced coagulopathy” </li></ul></ul><ul><ul><li>Some coders have been assigning: </li></ul></ul><ul><ul><ul><li>PDX: 286.5 Hemorrhagic disorder due to intrinsic circulating anticoagulants </li></ul></ul></ul><ul><ul><ul><li>SDX: 578.X GI bleeding; 784.7 Epistaxis; 599.7 Hematuria; 786.3 Hemoptysis </li></ul></ul></ul><ul><ul><li>“ Coumadin-induced” means that this was either an adverse reaction or a poisoning </li></ul></ul><ul><ul><ul><li>Adverse reaction: sequence the bleeding condition as PDX </li></ul></ul></ul><ul><ul><ul><li>Adverse reaction: sequence the adverse reaction (E934.2) as SDX </li></ul></ul></ul><ul><ul><ul><li>Poisoning: sequence the poisoning (964.2) as PDX </li></ul></ul></ul><ul><ul><ul><li>Poisoning: sequence the bleeding as SDX </li></ul></ul></ul>
  40. 40. Potential Overcoding: Beware! <ul><li>Coagulopathy </li></ul><ul><ul><li>Refer to Coding Clinic , 3 rd Quarter 2004, page 7 </li></ul></ul><ul><ul><li>Don’t forget other helpful codes for Coumadin-related conditions </li></ul></ul><ul><ul><ul><li>790.92 Abnormal coagulation profile </li></ul></ul></ul><ul><ul><ul><li>V58.61 Long-term (current) use of anticoagulants </li></ul></ul></ul>Coumadin Poisoning Hemoptysis Hematuria Epistaxis GI Bleeding Coagulopathy $3,443 $3,329 $3,138 $3,114 $5,098 $6,713 RW: 0.6886 RW: 0.6658 RW: 0.6276 RW: 0.6227 RW: 1.0195 RW: 1.3426 PDX: 964.2 PDX: 786.3 PDX: 599.7 PDX: 784.7 PDX: 578.9 PDX: 286.5 MS-DRG 918 MS-DRG 204 MS-DRG 696 MS-DRG 151 MS-DRG 378 MS-DRG 813
  41. 41. Potential Overcoding: Beware! <ul><li>Debridement </li></ul><ul><ul><li>Differentiation of excisional and non-excisional is required </li></ul></ul><ul><ul><ul><li>Excisional (86.22): surgical removal or cutting away of devitalized necrosis or slough; may be performed in the operating room, emergency department or at the patient bedside </li></ul></ul></ul><ul><ul><ul><li>Non-excisional (86.28): non-operative brushing, irrigating, scrubbing or washing away of devitalized tissue, necrosis or slough; may include whirlpool debridement </li></ul></ul></ul><ul><ul><li>The problem is usually in the documentation (or lack thereof) </li></ul></ul><ul><ul><ul><li>“Sharp” is not sufficient for excisional </li></ul></ul></ul><ul><ul><ul><li>The use of scissors does not necessarily equate to excisional </li></ul></ul></ul><ul><ul><li>An excisional debridement may be performed by a nurse, therapist, physician assistant or a physician ( Coding Clinic , 2 nd Quarter 2000, page 9) </li></ul></ul>
  42. 42. Potential Overcoding: Beware! <ul><li>Debridement </li></ul><ul><ul><li>Procedural details should be documented: </li></ul></ul><ul><ul><ul><li>Instruments used </li></ul></ul></ul><ul><ul><ul><li>Extent and depth of the procedure </li></ul></ul></ul><ul><ul><ul><li>Definite cutting away of tissue </li></ul></ul></ul><ul><ul><li>Excisional debridement should NOT be assigned if performed as a part of the following procedures: </li></ul></ul><ul><ul><ul><li>Incision and drainage </li></ul></ul></ul><ul><ul><ul><li>Bursectomy </li></ul></ul></ul><ul><ul><ul><li>Amputation </li></ul></ul></ul>
  43. 43. Potential Overcoding: Beware! <ul><li>Debridement </li></ul><ul><ul><li>For excisional debridements, the code assigned should reflect the deepest layer of tissue debrided </li></ul></ul><ul><ul><ul><li>Fascia </li></ul></ul></ul><ul><ul><ul><li>Muscle </li></ul></ul></ul><ul><ul><ul><li>Bone </li></ul></ul></ul><ul><ul><li>When there’s no specific indexed entry for a debridement site other than skin, look for other terms such as excision or destruction of lesion of that site. </li></ul></ul><ul><ul><ul><li>E.g., for excisional debridement of soft tissue </li></ul></ul></ul><ul><ul><ul><li>Excision, lesion </li></ul></ul></ul><ul><ul><ul><li>soft tissue NEC 83.39 </li></ul></ul></ul><ul><ul><ul><li>Refer to Coding Clinic , 2 nd Quarter 2006, pages 3-4 </li></ul></ul></ul>
  44. 44. Potential Overcoding: Beware! <ul><li>Debridement </li></ul><ul><ul><li>In some cases, the questions related to depth of debridement may relate the patient’s diagnosis. </li></ul></ul><ul><ul><ul><li>Necrotizing fasciitis -- Was fascia debrided? </li></ul></ul></ul><ul><ul><ul><li>Osteomyelitis – Was muscle, fascia or bone debrided? </li></ul></ul></ul><ul><ul><ul><li>Decubitus ulcer – Was muscle or fascia debrided? </li></ul></ul></ul><ul><ul><ul><li>Complicated wound – Was muscle, fascia, tendon, bursa or bone debrided? </li></ul></ul></ul>
  45. 45. Potential Overcoding: Beware! <ul><li>Debridement </li></ul><ul><ul><li>Coding Clinic , 1 st Quarter 2008, page 3 </li></ul></ul><ul><ul><ul><li>Must excisional debridement involve cutting outside or beyond the wound margin? Does the documentation specifically need to state this? </li></ul></ul></ul><ul><ul><ul><li>“ The clinical information published in Coding Clinic regarding excisional debridement and cutting outside of the wound margins was provided for informational purposes to aid the coder’s understanding. It was not intended as clinical criteria to report code 86.22.” </li></ul></ul></ul><ul><ul><ul><li>Some review organizations (including RACs) were interpreting the “must involve cutting outside or beyond the wound margin” literally. </li></ul></ul></ul>
  46. 46. Other RAC (MS-DRG) Related Target Issues <ul><li>Single CC/MCC DRGs </li></ul><ul><ul><li>Major bowel procedures </li></ul></ul><ul><ul><ul><li>MS-DRG 330 Major small & large bowel procedures with CC </li></ul></ul></ul><ul><ul><ul><li>PDX of malignant neoplasm of intestine (15X.X) </li></ul></ul></ul><ul><ul><ul><ul><li>SDX (and only CC) of lymph node metastasis (196.X) </li></ul></ul></ul></ul><ul><ul><ul><li>PDX of diverticulitis (562.11) </li></ul></ul></ul><ul><ul><ul><ul><li>SDX (and only CC) of abscess of intestine (569.5) </li></ul></ul></ul></ul><ul><ul><li>Issue: RAC is looking for diagnoses documented ONLY on pathology report </li></ul></ul><ul><ul><ul><li>Some coders are coding 569.5 for “microperforations” or “microabscesses” on pathology report. These are present in nearly ALL diverticulitis cases. </li></ul></ul></ul>
  47. 47. Other RAC (MS-DRG) Related Target Issues <ul><li>Single CC/MCC DRGs </li></ul><ul><ul><li>Issue: RAC is looking for diagnoses documented ONLY on pathology report </li></ul></ul><ul><ul><li>See Coding Clinic , 1 st Quarter 2004, page 20: </li></ul></ul><ul><ul><ul><li>“ When coding strictly from the pathology report, the coder is assigning a diagnosis based on the pathological findings alone without the attending physician's corroboration. Although the pathologist provides a written interpretation of a tissue biopsy, this is not equivalent to the attending physician's medical diagnosis based on the patient's complete clinical picture. The attending physician is responsible for and directly involved in the care and treatment of the patient.” </li></ul></ul></ul>
  48. 48. Other RAC (MS-DRG) Related Target Issues <ul><li>Single CC/MCC DRGs </li></ul><ul><ul><li>Acute blood loss anemia (285.1) assigned as only CC for hip ORIF and other related procedures </li></ul></ul><ul><ul><li>Moves MS-DRG from 482 to 481 Hip & Femur Procedures Except Major Joint (without and with CC) </li></ul></ul><ul><ul><li>Refer to Coding Clinic , 1 st Quarter 2007, page 19 </li></ul></ul><ul><ul><li>When postoperative anemia is documented without specification of acute blood loss, code 285.9, Anemia, unspecified, is the default.  Code 285.1, Acute posthemorrhagic anemia, should be assigned, when postoperative anemia is due to acute blood loss.  Revisions were made to the Alphabetic Index in 2004, which direct the coder in the following manner: </li></ul></ul><ul><ul><li>Anemia </li></ul></ul><ul><ul><li>                        postoperative </li></ul></ul><ul><ul><li>                              due to blood loss  285.1 </li></ul></ul><ul><ul><li>                                    other 285.9 </li></ul></ul>
  49. 49. Conclusions <ul><li>Yes, MS-DRGs are similar to the old CMS-DRGs but we have different issues </li></ul><ul><ul><li>Watch sequencing; just because a particular sequenced set of diagnoses gets you an MCC, it doesn’t mean it’s the appropriate code assignment for the case. </li></ul></ul><ul><ul><li>Medicare still accepts only 9 diagnoses and 6 procedures; make sure the most important and those reflecting the highest severity are ranked the highest in order. </li></ul></ul><ul><ul><li>The learning curve will improve and productivity may also, although possibly not back to pre-MS-DRG levels. </li></ul></ul><ul><ul><li>Ensure each condition addressed/treated is coded, but don’t overmaximize – Coding Clinic still rules. </li></ul></ul>
  50. 50. Conclusions <ul><li>Most facilities are seeing: </li></ul><ul><ul><li>Increase in: </li></ul></ul><ul><ul><ul><li>Accounts Receivable (AR) dollars </li></ul></ul></ul><ul><ul><ul><li>Average time required to code an inpatient record </li></ul></ul></ul><ul><ul><ul><li>Number of physician queries required to code adequately and completely for MS-DRGs </li></ul></ul></ul><ul><ul><ul><li>Need for physician education re: documentation specificity </li></ul></ul></ul><ul><ul><li>Still to be determined: </li></ul></ul><ul><ul><ul><li>Impact on CMI; this will largely be determined by size of facility and types of services provided </li></ul></ul></ul><ul><ul><ul><li>Whether CMS’ idea of the need for a “behavioral offset” was legitimate </li></ul></ul></ul>
  51. 51. Conclusions <ul><li>What everyone should be doing: </li></ul><ul><ul><li>Data mining; if the RACs, QIOs and other government agencies are looking at your data, you should be too! </li></ul></ul><ul><ul><ul><li>Start with some of the potential overcoding issues identified here </li></ul></ul></ul><ul><ul><ul><li>Track progress over time </li></ul></ul></ul><ul><ul><ul><li>Use public databases from the existing Payment Error Programs </li></ul></ul></ul><ul><ul><ul><ul><li>Hospital Payment Monitoring Program (HPMP) </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Medicare inpatient cases </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Previously called the Payment Error Prevention Program (PEPP) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Reviews that are performed by the QIOs </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Monitor your Program for Evaluating Payment Patterns Electronic Report (PEPPER) </li></ul></ul></ul></ul></ul>
  52. 52. Questions? <ul><li>It’s an exciting time in HIM, with MS-DRGs, POA, RACs, MACs, etc. </li></ul><ul><li>Please contact me if you wish – </li></ul><ul><ul><li>[email_address] </li></ul></ul>

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