Respiratory
          Neoplasm



Charmira Orr BS,LPN,CCS,CPC,CCDS
      Director of Coding and Appeals
         Intersect...
Learning Objectives
           Participants will review and understand
           the RAC’s focus

           Participants...
The RAC’s Focus




  2010 Intersect Healthcare, Inc.   3




                                        3
Diagnostic
              Information



                                     Procedures
Discharge




                  Di...
MS‐DRG 180,181,182
       Issue Details Name Respiratory 175, 176, 180, 181, 182, 183, 184, 185, 186, 187, 188, 192, 196,
...
Things We Know
Without CC/ CC
 ih     CC/MCC                     •    GMLOS 3.0,
                                        G...
Principle Diagnosis
• The condition found after study to have occasioned the 
  current admission or encounter

• The majo...
PRIMARY VS. SECONDARY
SEQUENCING GUIDELINES




       2010 Intersect Healthcare, Inc.   8




                           ...
PRIMARY
When treatment is directed toward the primary site,
 the malignancy of that site is designated as the
 principal d...
Follow the Treatment
If there are 2 primary sites, however, treatment is 
directed primarily toward one site, that site sh...
Secondary Sites
If treatment is directed only at the secondary 
   site, the secondary site is designated as the 
   princ...
Presumed Secondary
       Neoplasm
Mediastinum
   di   i
Meninges
Peritoneum
Pleura
Retroperitoneum
Spinal Cord
Sites Clas...
Secondary Diagnosis
   Diagnoses that coexist at the time of admission or
develop subsequently or affect patient care for ...
Common CC/MCC Conditions
•   Asthma w/acute
       h      /                 •   Aspiration pneumonia
                     ...
Common Diagnostic Procedures

•   CXR
•   CT scans
•   PET scans
•   Sputum Cytology
•   Biopsies
•   Bronchoscopy
•      ...
Common Treatments
•   Radiotherapy, Immunotherapy, or Ch
       di h                  h          Chemotherapy
            ...
Documentation Highlights
• Acute vs. chronic
• Diagnostic test –documented diagnosis
• Diagnostic reports- document diagno...
Auditing for Neoplasm




     2010 Intersect Healthcare, Inc.   18




                                            18
Worksheet
Length of stay: 
      h f
Discharge status:  
Home or Self Care ‐01
Discharged/ Transferred to a Short Term Gen...
Worksheet
Admission Orders: 
 d i i Od
Malignant condition noted
Was treatment during stay directed at this area:    Yes o...
Worksheet
Is the primary malignancy still present, but treatment is directed at the secondary site 
    h     i        li ...
Appealing a
     Respiratory
     Neoplasms
   Inpatient Denial


‘Yomi Faparusi, MD JD PhD
Director, Medical Review and R...
Learning Objectives
           Understand how to create a successful
           coding or medical necessity appeal for
   ...
Understanding the Issue
            at Hand
           Top target MS DRG during RAC demonstration
           project

    ...
Understanding the Issue
            at Hand
           Usually an “outlier” inpatient case
                       outlier
...
The Appeal Algorithm
                     NCD



                      LCD



                   COMMUNITY
               ...
NCDs & LCDs
           NCD
           Ensure effective on the date of service (may have been retired)
              Aprepi...
Providing a Road Map
                                                Justification of Medical Necessity
                  ...
Preponderance of
                         Evidence
       ACCP EVIDENCE-BASED GUIDELINES
                 American College...
Preponderance of
                          Evidence

              •   ACCP PUBLICATIONS
              •   HOME
          ...
Preponderance of
                         Evidence
                 American Society of Clinical Oncology
                ...
Parting Thoughts
           Use the guidelines that were available and in effect at the 
           Use the guidelines tha...
Summary
           Best Practice for Appeal
                 Determine if documentation in the chart
                 supp...
Resources
       THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM:
       An Evaluation of the 3-Year Demonstration, J...
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MS-DRG 180-181-182 slides

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Respiratory Neoplasm RAC's Focus

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MS-DRG 180-181-182 slides

  1. 1. Respiratory Neoplasm Charmira Orr BS,LPN,CCS,CPC,CCDS Director of Coding and Appeals Intersect Healthcare, Inc. 1
  2. 2. Learning Objectives Participants will review and understand the RAC’s focus Participants will review and understand how to incorporate g p guidelines to aid in auditing practices 2010 Intersect Healthcare, Inc. 2 2
  3. 3. The RAC’s Focus 2010 Intersect Healthcare, Inc. 3 3
  4. 4. Diagnostic Information Procedures Discharge Diagnosis 2010 Intersect Healthcare, Inc. 4 4
  5. 5. MS‐DRG 180,181,182 Issue Details Name Respiratory 175, 176, 180, 181, 182, 183, 184, 185, 186, 187, 188, 192, 196, 197, 198, 199, 200, 201, 202, 203, 204, 205, 206 (Medical Necessity Excluded) Number B001232010 Description MS-DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded on the hospital claim, matches both the attending physician description and the information contained in the medical record. Reviewers will validate MS-DRGs 175, 176, 180, 181, 182, 183, 184, 185, 186, 187, 188, 192, 196, 197, 198, 199, 200, 201, 202, 203, 204, 205 and 206 for diagnoses and procedures affecting the MS- DRG assignment. Claim Type Inpatient Issue Type Complex Overpayment / Underpayment Overpayment and Underpayment Dates of Service 10/1/2007 - Open States IL, IN, KY, MI, MN, OH, OH WI Policy Related Links ICD 9 CM Coding Manual (for dates of service on claim) ICD-9-CM ICD-9-CM Addendums and coding clinics PIM Ch 6.5.3, Section A – C - DRG Validation Review Present on Admission Indicator Systems Implementation OIG - Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99) Date Approved 6/10/2010  CGI Federal , 2010 © 2010 Intersect Healthcare, Inc. 5 5
  6. 6. Things We Know Without CC/ CC ih CC/MCC • GMLOS 3.0, G OS 3 0 RW 0.8159 0 81 9 With CC • GMLOS 4.3, RW 1.2062 With MCC • GMLOS 5.9, RW 1.7263 Principle Diagnosis • Malignant, Secondary, Benign, In situ, Lipoma’s 2010 Intersect Healthcare, Inc. 6 6
  7. 7. Principle Diagnosis • The condition found after study to have occasioned the  current admission or encounter • The majority of treatment can often be used as a guide to  selecting the principal diagnosis selecting the principal diagnosis • Primary and Secondary Sites 2010 Intersect Healthcare, Inc. 7 7
  8. 8. PRIMARY VS. SECONDARY SEQUENCING GUIDELINES 2010 Intersect Healthcare, Inc. 8 8
  9. 9. PRIMARY When treatment is directed toward the primary site, the malignancy of that site is designated as the principal diagnosis unless the encounter or hospital admission is solely for the purpose of radiotherapy, chemotherapy, or immunotherapy py, py, py – Then the primary malignancy is a secondary diagnosis, Encounter ( V-Codes ) First – If two primary sites are present, each is coded p y p , as a primary neoplasm 2010 Intersect Healthcare, Inc. 9 9
  10. 10. Follow the Treatment If there are 2 primary sites, however, treatment is  directed primarily toward one site, that site should  be designated as the principal diagnosis If treatment is directed  equally toward both sites,  either may be designated as the principal diagnosis 10
  11. 11. Secondary Sites If treatment is directed only at the secondary  site, the secondary site is designated as the  principal diagnosis – An additional code is assigned for the primary  malignancy – A  V ‐ code is assigned as the additional code if the  primary site has resolved 2010 Intersect Healthcare, Inc. 11 11
  12. 12. Presumed Secondary Neoplasm Mediastinum di i Meninges Peritoneum Pleura Retroperitoneum Spinal Cord Sites Classifiable to 195 Bone Brain Diaphragm Heart Liver Lymph nodes 2010 Intersect Healthcare, Inc. 12 12
  13. 13. Secondary Diagnosis Diagnoses that coexist at the time of admission or develop subsequently or affect patient care for the current hospital episode. Should only be documented when? Clinically Evaluated Increase  Diagnostically  nursing care or  Tested monitoring Therapeutically  Increased LOS Treated 13 13
  14. 14. Common CC/MCC Conditions • Asthma w/acute h / • Aspiration pneumonia i i i exacerbation or status • Empyema asthmaticus • Pneumonia • Bronchitis w/ acute • Pulmonary embolism exacerbation • Lung Abscess • CKD • Spontaneous tension • Respiratory insufficiency pneumothorax • Pulmonary edema • Mediastinitis • Pneumothorax • Bacterial pleural effusion • Tracheostomy • Acute Respiratory Failure p y complications li ti 14
  15. 15. Common Diagnostic Procedures • CXR • CT scans • PET scans • Sputum Cytology • Biopsies • Bronchoscopy • py Mediastinoscopy • Bone scans 2010 Intersect Healthcare, Inc. 15 15
  16. 16. Common Treatments • Radiotherapy, Immunotherapy, or Ch di h h Chemotherapy h • When a patient encounter is solely for the administration of chemotherapy, immunotherapy, or radiation therapy, assign the appropriate code as the first-listed or principal diagnosis - ( V –Codes) • If the encounter is to receive one or more of these therapies, each pertinent code should be assigned, in any sequence • Additional code should be assigned for the malignancy • Procedure codes should also be assigned – 92 2x Radiation therapy 92.2x – 99.28 Immunotherapy – 99.25 Chemotherapy 2010 Intersect Healthcare, Inc. 16 16
  17. 17. Documentation Highlights • Acute vs. chronic • Diagnostic test –documented diagnosis • Diagnostic reports- document diagnosis in progress notes • I iti t d t Initiated treatment or plans t t l • Severity of condition • Etiology of condition 2010 Intersect Healthcare, Inc. 17 17
  18. 18. Auditing for Neoplasm 2010 Intersect Healthcare, Inc. 18 18
  19. 19. Worksheet Length of stay:  h f Discharge status:   Home or Self Care ‐01 Discharged/ Transferred to a Short Term General Hospital for Inpatient Care ‐ 02 Discharged/ Transferred to a SNF with Medicare Certification in Anticipation  of killed Care ‐ 03 Discharged/Transferred to an Intermediate Care Facility ‐ 04 Discharged/Transferred to Another Type of Health Care Facility Not elsewhere  in the Code List‐ 05 Discharged/ Transferred to Home Care‐ 06 AMA ‐07 Expired‐20 2010 Intersect Healthcare, Inc. 19 19
  20. 20. Worksheet Admission Orders:  d i i Od Malignant condition noted Was treatment during stay directed at this area:    Yes or No  Was patient admitted for treatment only?  Yes or No  Were there any complications noted during stay? Yes or No  If so, please  list_________________________________________________________________ list _________ Were any procedures performed on either the primary or secondary malignancy?    Drop Down Box   Yes or No   If so; please list ‐‐‐‐‐‐‐‐‐‐  Then area to fill in the  blank______________________________________________________________ _______________ Is there any mention in the medical record that a primary malignancy has been  Is there any mention in the medical record that a primary malignancy has been excised or eradicated?   Box Yes or No   if so; is there any treatment directed at this  area?  Yes or No   2010 Intersect Healthcare, Inc. 20 20
  21. 21. Worksheet Is the primary malignancy still present, but treatment is directed at the secondary site  h i li ill b i di d h d i only during the admission?   Secondary diagnosis:   ___________________________________________________________________ __ Were these diagnoses treated during pt. stay? Yes or No   if so; list  Fill in the blank  treatments__________________________________________________________ __________ 2010 Intersect Healthcare, Inc. 21 21
  22. 22. Appealing a Respiratory Neoplasms Inpatient Denial ‘Yomi Faparusi, MD JD PhD Director, Medical Review and Research, Intersect Healthcare, Inc. 1
  23. 23. Learning Objectives Understand how to create a successful coding or medical necessity appeal for Respiratory Neoplasms denials by: Understanding the Issue at Hand Providing a Road Map for the Reviewer Presenting a Preponderance of Best Evidence Understand how to tailor appeals to the Administrative Law Judge 2010 Intersect Healthcare, Inc. 2 2
  24. 24. Understanding the Issue at Hand Top target MS DRG during RAC demonstration project Historically have been identified as problematic DRGs National Validation Study: HHS-OIG recommended review of admissions Short hospitalization with relatively hi h unnecessary Sh t h it li ti ith l ti l high admission rates PEPPER data (FY 2007) Error rate of 11% DRG changes: 5% ; Admission denials: 6% Key Learning: Respiratory Neoplasms expected to  maintain status with the permanent RAC program especially  with Medical Necessity audits. 2010 Intersect Healthcare, Inc. 3 3
  25. 25. Understanding the Issue at Hand Usually an “outlier” inpatient case outlier Rarely need inpatient admissions Short hospitalization Admitted when patient presents with complications and/or for management of co morbidities Bleeding Obstructive Hormonal (ectopic production) etc. Occupational and Social issues Smoking Coal mining Asbestos e pos e exposure Key Learning: Most patients with respiratory neoplasms are treated  as outpatient hence look for documentation why index case is inpatient 2010 Intersect Healthcare, Inc. 4 4
  26. 26. The Appeal Algorithm NCD LCD COMMUNITY STANDARDS OF MEDICAL CARE TREATING OR LIMITATION ATTENDING OF LIABILITY PHYSICIAN RULE RULE 2010 Intersect Healthcare, Inc. 5 5
  27. 27. NCDs & LCDs NCD Ensure effective on the date of service (may have been retired) Aprepitant for Chemotherapy-Induced Emesis (110.18) Certain Drugs Distributed by the National Cancer Institute (110.2) Erythropoesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions ( p (110.21) ) LCD Check with your FI etc. Key Learning: The ALJ is bound by the NCDs however may consider the LCDs at his/her discretion 2010 Intersect Healthcare, Inc. 6 6
  28. 28. Providing a Road Map Justification of Medical Necessity J tifi ti f M di l N it The arguments presented below justify the medical necessity of hospital services.  Just as importantly, the arguments justify that  the hospital services provided are “generally accepted by the professional community as being safe and effective treatment.” Signs and Where Skilled Outcome of Source of Symptoms or Documented Intervention(s) Intervention Recommendation Complications Drowsiness, Physician’s Intubated; I.V. Mental status Dr. Miller (see Confusion, admission hypertonic changes Nephrology Seizures notes dated saline at reversed and Consult notes 3/10/2010; 125mL/h for 3 patient no dated 3/10/2010; *Hyponatremia entered hours page 32 (of 175) longer had electronically of the Medical seizures by Dr. Glenn; Record Page 27 (of 175) of the Medical Record 2010 Intersect Healthcare, Inc. 7 7
  29. 29. Preponderance of Evidence ACCP EVIDENCE-BASED GUIDELINES American College of Chest Physicians Health and Science Policy Committee Diagnosis and management of lung cancer Reviewed annually for new developments Most current ACCP guidelines for lung cancer were published in the September 2007 supplement edition of CHEST American College of Chest Physicians. (2007). Diagnosis and Management of Lung Cancer: ACCP Guidelines. CHEST: 132 (3suppl.) http://chestjournal.chestpubs.org/content/132/3_suppl 2010 Intersect Healthcare, Inc. 8 8
  30. 30. Preponderance of Evidence • ACCP PUBLICATIONS • HOME • CURRENT ISSUE • ARCHIVE • FEEDBACK • SUBSCRIBE • ALERTS • HELP Table of Contents September 1 2007; 132 (3 suppl) 1, Diagnosis and Management of Lung Cancer: ACCP Guidelines   2010 Intersect Healthcare, Inc. 9 9
  31. 31. Preponderance of Evidence American Society of Clinical Oncology (ASCO) Non small cell lung cancer (NSCLC) guidelines American Society for Clinical Oncology (ASCO). (2009). Clinical Practice Guideline, Lung Cancer. http://www.asco.org/ASCOv2/Practice+%26+Guidelines/ p g Guidelines/Clinical+Practice+Guidelines/Lung+Cancer Other professional associations As applicable to the management of complications or co morbidities 2010 Intersect Healthcare, Inc. 10 10
  32. 32. Parting Thoughts Use the guidelines that were available and in effect at the  Use the guidelines that were available and in effect at the time the services were provided, coded, and billed! Provide clear and accurate reference information,  including URLs. Include all supporting guidelines in full text documents  pp gg (the pertinent pages) as attachments to your appeal. 2010 Intersect Healthcare, Inc. 11 11
  33. 33. Summary Best Practice for Appeal Determine if documentation in the chart supports an appeal Support the coding decision with: ICD‐9‐CM Coding Guidelines IC 9 CM Official Guidelines for Coding and Reporting ICD‐9‐CM Official Guidelines for Coding and Reporting  American Hospital Association's (AHA) Coding Clinic for ICD‐9‐CM Support the physician’s decision making process with evidence based guidelines Use CMS’s coverage policies and guidelines 2010 Intersect Healthcare, Inc. 12 12
  34. 34. Resources THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM: An Evaluation of the 3-Year Demonstration, June 2008 https://www.cms.gov/RAC/Downloads/RACEvaluationReport.pdf Official ICD-9-CM Guidelines for Coding and Reporting Effective October 1, 2009 http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm American College of Chest Physicians. (2007). Diagnosis and Management of Lung Cancer: ACCP Guidelines. CHEST: 132 (3suppl.) http://chestjournal.chestpubs.org/content/132/3_suppl American Society for Clinical Oncology (ASCO). (2009). Clinical Practice Guideline, Lung Cancer. http://www.asco.org/ASCOv2/Practice+%26+Guidelines/Guidelines/Clinica htt // /ASCO 2/P ti +%26+G id li /G id li /Cli i l+Practice+Guidelines/Lung+Cancer 2010 Intersect Healthcare, Inc. 13 13

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