Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Top MS-DRG’s at Risk
      MS-
Documentation, Coding Audit, and Appeal Workshops
         Sponsored by Intersect Healthcar...
MS DRG 207:
   Respiratory Failure with
 Ventilator Support >96 hours
 V til t    S     t     h


                        ...
What are the Causes of
                      Respiratory Failure?
          Alveolar Hypoventilation
            – Drug ov...
What are the Challenges in Physician
Documentation of Respiratory Failure?


           The use of the term “respiratory i...
When is ventilatory support considered
Non-invasive mechanical ventilation?

           BiPAP S/T-D ventilatory support sy...
What are the Challenges in Physician
               Documentation of a Patient
                 Already on a Ventilator?
 ...
Example:
           A 24-year-old female throws a massive
           pulmonary embolus, requires intubation,
           an...
When in Doubt…



           Refer to Coding Clinics

           Query, query, query!




2010 Intersect Healthcare, Inc. ...
The RAC
                       and
                    MS DRG
                    MS-DRG 207



    C a
    Charmira Orr B...
The RAC Demonstration

Wrong Principal Diagnosis-RACs found that the
                 Diagnosis RACs
principal diagnoses o...
Respiratory System Diagnosis with Ventilator
     Support >96 Hours (MS-DRG 207)


    MDC4                           GMLO...
Mechanical Ventilation –ICD-9
    96.7 Guidelines Cont’d
Endotracheal Intubation
To calculate the number of hours (duratio...
Process Steps to Auditing the
                   Medical Record
           1.          Examine - The medical record to ens...
Abstraction Worksheet Cont’d
12.     Was treatment during stay directed at the Malignant conditions?                      ...
The Story


Principal Diagnosis   Documentation to support   Secondary Diagnosis   Procedures   MS-DRG




               ...
Coding Clinics

Intubation / Mechanical Ventilation
  /Respiratory Failure
  Absence of intubation and mechanical ventilat...
References


HTTP://LIBRARY.AHIMA.ORG/XPEDIO/GROUPS/PUBLIC/DOCUMENTS/AHIMA/BOK1_043474.HCSP?D
DOCNAME=BOK1_043474

HTTP://...
Learning Objectives
• Understand how to create a successful
  coding or medical necessity appeal for
  Respiratory System ...
Understanding the Issue at Hand

In 1996, it was estimated that 7% of DRG 475 
should have been coded to a lower weight DR...
Planning for Appeals
Considerations for Deciding to Appeal
 – Cost
 – Time
 – Resources
 – Chance of Overturn
      First ...
Building the Foundation




     http://racb.cgi.com/Issues.aspx



                               2010 Intersect Healthca...
Creating the Structure
Use the Best Evidence
– CMS Internet Only Manuals (IOM)
– National Coverage Determinations; Local
 ...
Providing a Road Map
                                                                    http://www.ama‐
                 ...
Providing a Road Map




      2010 Intersect Healthcare, Inc.   47




Providing a Road Map




      2010 Intersect Heal...
Preponderance of Evidence
• Indications for Mechanical Ventilation
      – http://www.merck.com
      – Indications: There...
Capping the Issue
Use guidelines in place at the time care was provided

Include an Attachments List

Include all Attachme...
Upcoming SlideShare
Loading in …5
×

MS-DRG 207 slides

5,387 views

Published on

Respiratory Failure with Ventilator Support >96 Hours (MS-DRG 207)

Learn How to avoid RAC denials and file an effective appeal

  • Excellent post , For my two cents , if anyone was looking for a CA DL 207 , my business partner filled a fillable form here DL Request.
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

MS-DRG 207 slides

  1. 1. Top MS-DRG’s at Risk MS- Documentation, Coding Audit, and Appeal Workshops Sponsored by Intersect Healthcare, Inc. Part Three: Respiratory Failure with Ventilator Support >96 hours (MS-DRG 207) Next Session: Wednesday, July 7 W d d J l 1:00PM EST Chest Pain (1 day stay): A Clinical Documentation, Coding Audit & Appeal Workshop (MS-DRG 313) Top MS-DRG’s at Risk MS- Documentation, Coding Audit, and Appeal Workshops Sponsored by Intersect Healthcare, Inc. Part Three: Respiratory Failure with Ventilator Support >96 hours (MS-DRG 207) Your Panel: Tracey Goessel, MD Clinical Overview of MS-DRG 207 Charmira Johnson, CCS, BS, LPN, CCDS The RAC and MS-DRG 207 Denise Wilson, RN, RRT, MS Appealing a MS-DRG 207 Denial 1
  2. 2. MS DRG 207: Respiratory Failure with Ventilator Support >96 hours V til t S t h Tracey Goessel, M.D. CEO FairCode Associates What is “Respiratory Failure”? Inability of the lungs to p y g perform their basic task of gas exchange: the transfer of oxygen from inhaled air into the blood and the transfer of carbon dioxide from the blood into exhaled air. We tend to think of it as being a state where the patient’s oxygen is too low; but it can be also a state where the CO2 is too high. 2010 Intersect Healthcare, Inc. FairCode 4 2
  3. 3. What are the Causes of Respiratory Failure? Alveolar Hypoventilation – Drug overdose/respiratory suppressants – Chest wall trauma – Neurologic disorders (stroke, MS), Neuromuscular disorders (myasthenia gravis), Muscular disorders (muscular dystrophy) Capillary wall/alveolar damage – Near drowning – Pesticide exposure – Smoke inhalation/fire Inadequate alveolar wall surface – COPD! Loss of elasticity in the lungs – Pulmonary fibrosis – Sarcoidosis – ~ 100 others Loss of pulmonary vascular bed – Massive pulmonary embolism 2010 Intersect Healthcare, Inc. FairCode 5 How Do We Diagnose Respiratory Failure – From a Clinical and Coding Standpoint? In patients without underlying disease, the general rule of thumb is p g pO2 < 60 and/or the pCO2 > 50. COPD patients often have baseline pO2s that are low and pCO2s that are elevated. Look at pH: is patient acidotic, or compensated? Drop of 10-15 points in p p p pO2 from baseline is suggestive. Patient does not need to be on ventilator for respiratory failure to be the diagnosis! 2010 Intersect Healthcare, Inc. FairCode 6 3
  4. 4. What are the Challenges in Physician Documentation of Respiratory Failure? The use of the term “respiratory insufficiency” as a synonym. The failure to document baseline blood gases in COPD patients The hesitancy to document respiratory failure if the patient is not on a ventilator. 2010 Intersect Healthcare, Inc. FairCode 7 When is ventilatory support considered Non-invasive mechanical ventilation? BiPAP S/T-D ventilatory support system: augments patient’s ability to breath on their own – while it is continuous, continuous it does not qualify as “continuous continuous manual ventilation” because it is not given via ET/NT or trach tube CPAP - continuous positive airway pressure not through ET/NT or trach tube NIPPV - noninvasive positive pressure ventilation i i iti til ti NPPV - nonpositive pressure ventilation PEEP - not given via ET/NT or trach tube 2010 Intersect Healthcare, Inc. FairCode 8 4
  5. 5. When is ventilatory support considered Non-invasive mechanical ventilation? BiPAP S/T-D ventilatory support system: augments patient’s ability to breath on their own – while it is continuous, continuous it does not qualify as “continuous continuous manual ventilation” because it is not given via ET/NT or trach tube CPAP - continuous positive airway pressure not through ET/NT or trach tube NIPPV - noninvasive positive pressure ventilation i i iti til ti NPPV - nonpositive pressure ventilation PEEP - not given via ET/NT or trach tube 2010 Intersect Healthcare, Inc. FairCode 9 When is Ventilatory Support Considered Invasive Mechanical Ventilation? BiPAP though given via ET/NT or trach tube CPAP given via ET/NT or trach tube (mostly!) PEEP given via ET/NT or trach tube IPPV - invasive positive p p pressure ventilation 2010 Intersect Healthcare, Inc. FairCode 10 5
  6. 6. What are the Challenges in Physician Documentation of a Patient Already on a Ventilator? Capturing when the post-operative period on a ventilator counts as an “unexpected, extended period of mechanical ventilation ” ventilation. Capturing the time of intubation. Anesthesia records usually precise; ER records less so. Incision of tracheotomy/cricothyroidostomy represents moment of intubation in surgical airways. Capturing the time of extubation extubation. Oral/nasotracheal intubation: ends when tube pulled. Weaning periods count with trach patients. Tube may remain indefinitely, so once pt weaned off mechanical ventilation, that is when clock stops. Respiratory therapy notes generally more helpful and specific than MD notes 2010 Intersect Healthcare, Inc. FairCode 11 What are the Challenges in Determining When to Make Respiratory Failure Principal Diagnosis? Respiratory failure is not a symptom. It is a diagnosis. As such, it may be coded as the principal diagnosis, diagnosis even when the cause is known known. For the most part, if respiratory failure is present at admission, it trumps the underlying cause. You list it first. Chapter-specific coding guidelines may over-ride this thi rule: l – Obstetrics – Poisoning – HIV – Newborns 2010 Intersect Healthcare, Inc. FairCode 12 6
  7. 7. Example: A 24-year-old female throws a massive pulmonary embolus, requires intubation, and is on the ventilator for 5 days. – If the embolus is a peri-partum pulmonary embolism, then OB sequencing guidelines require you to list PE first. This leads you to 781/782 Other Antepartum Diagnoses with or without Medical Complications – If the embolus is not obstetric in nature, then respiratory failure may be sequenced first, leading to MS DRG 207. 2010 Intersect Healthcare, Inc. FairCode 13 Accordingly: Work to get the attending to specify the cause of the respiratory failure. If he/she documents that it is a cause outside of the poisoning/HIV/newborn/obstetric arena, you may code respiratory failure first. 2010 Intersect Healthcare, Inc. FairCode 14 7
  8. 8. When in Doubt… Refer to Coding Clinics Query, query, query! 2010 Intersect Healthcare, Inc. FairCode 15 Sample Queries Respiratory Insufficiency – The term “respiratory insufficiency” is not specific from a coding standpoint. The patient presented with pneumonia, cyanosis and the following blood gases: pH 7.29/pO2 57/pCO2 49/HCO3 15. Please define the condition that was the underlying cause of the above documented laboratory studies. Unexpected, extended period of ventilation – The patient underwent an anterior/posterior cervical fusion. Post- operatively, you noted “extensive anterior edema” and maintained the patient on a ventilator for 18 hours in the ICU. In your opinion, does this represent a normal post-operative ventilatory duration, an extended post- operative ventilatory duration, or are you unable to determine? Underlying cause of respiratory failure – This patient presented with respiratory failure requiring mechanical ventilation. He was documented to have consumed an overdose of Tylenol, requiring Mucomyst administration, as well as bi-lobar aspiration pneumonia. Please define what, in your opinion, was the underlying cause of the respiratory failure, if known. Copyright 2009 5 16 2010 Intersect Healthcare, Inc. FairCode 8
  9. 9. The RAC and MS DRG MS-DRG 207 C a Charmira Orr BS, LPN, CCS, CPC, CCDS aO S, , CCS, C C, CC S Intersect Healthcare, Inc. Learning Objectives To U d T Understand How to Use Past Findings t dH t U P t Fi di of the RAC Demonstration Area to Help Tell Your Coding Validation Story To Understand How to Break Down the Guidelines to Abstract Data from the Medical Record To Understand How to Tell Your Coding Validation Story 2010 Intersect Healthcare, Inc. 18 9
  10. 10. The RAC Demonstration Wrong Principal Diagnosis-RACs found that the Diagnosis RACs principal diagnoses on claims did not match the principal diagnoses in the medical record. For example, respiratory failure (code 518.81) was listed as the principal diagnosis, but the medical record indicated other conditions such as sepsis (code 038.0–038.9) was the principal diagnosis. In 2007 42% of the recoupment s were directly attributed t i tt ib t d to incorrect coding t di In NY $ 9.5 Million collected, CA $ 4.1 million collected, FL $1.7 Million collected. 2010 Intersect Healthcare, Inc. 19 Connolly Healthcare ©2010 Issue Name: Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207 (At this time, Medical Necessity excluded from review). Description: DRG Validation requires that diagnostic and procedural information and the DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS DRG 207, previously DRG 565, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia (WPS only), West Virginia (WPS only) Additional Information: Additional information can be found on the following manuals/publications: ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H ICD-9-CM Addendums and Coding Clinics PIM Ch. 6.5.3, Section A-C DRG Validation Review 2010 Intersect Healthcare, Inc. 20 10
  11. 11. Respiratory System Diagnosis with Ventilator Support >96 Hours (MS-DRG 207) MDC4 GMLOS/RW AND • GMLOS‐ • Non Operating  • Medical‐ Room  Any  12.8 Procedures Principal  • RW 5.1055  • ICD‐9 CM 96.72‐ Continuous  Diagnosis  • Transfer  invasive  in MDC 4 in MDC 4 DRG mechanical  mechanical ventilation for  96 consecutive  hours or more 2010 Intersect Healthcare, Inc. 21 Understanding the Guidelines The Uniform Hospital Discharge Data Set ( UHDDS) defines the principal diagnosis as the condition established after study and is the primary reason responsible for the admission of the patient to the acute care setting within the hospital. In accordance to coding guidelines the reason and circumstances that led to the inpatient admission must take precedence as the primary diagnosis. - ICD- 9 codes Various respiratory Conditions throughout the Index AND Mechanical Ventilation- Located under ICD-9 code 96.7 Includes: BiPAP delivered through endotracheal tube or tracheostomy (invasive interface) CPAP delivered through endotracheal tube or tracheostomy (invasive interface) Endotracheal respiratory assistance, Invasive positive pressure ventilation [IPPV] Mechanical ventilation through invasive interface That by tracheostomy Weaning of an intubated (endotracheal tube) patient Excludes: Noninvasive ventilation like face mask, nasal cannulas, nasal catheters 2010 Intersect Healthcare, Inc. 22 11
  12. 12. Mechanical Ventilation –ICD-9 96.7 Guidelines Cont’d Endotracheal Intubation To calculate the number of hours (duration) of continuous mechanical ventilation during a hospitalization, begin the count from the start of the (endotracheal) intubation. The duration ends with (endotracheal) extubation extubation. If a patient is intubated prior to admission, begin counting the duration from the time of the admission. If a patient is transferred (discharged) while intubated, the duration would end at the time of transfer (discharge). For patients who begin on (endotracheal) intubation and subsequently have a tracheostomy performed for mechanical ventilation, the duration begins with the (endotracheal) intubation and ends when the mechanical ventilation is turned off (after the weaning period). Tracheostomy To calculate the number of hours of continuous mechanical ventilation during a hospitalization, begin counting the duration when mechanical ventilation is started. The duration ends when the mechanical ventilator is turned off (after the weaning period). If a patient has received a tracheostomy prior to admission and is on mechanical ventilation at the time of admission, begin counting the duration from the time of admission. If a patient is transferred (discharged) while still on mechanical ventilation via tracheostomy, the duration would end at the time of the transfer (discharge). Please Note Must code in addition If performed: endotracheal tube insertion (96.04) tracheostomy (31.1-31.29 2010 Intersect Healthcare, Inc. 23 Auditing to tell the Story Examine Query Review Track Documentation Abstract Data Identify Code Compare 12
  13. 13. Process Steps to Auditing the Medical Record 1. Examine - The medical record to ensure that it is a complete record. Physician p y attestation statement and Discharge Summary is on the record, as well as nurses notes, treatment records and etc.. 2. Review - Must review the Entire Medical Record to accurately assign the principal and secondary diagnosis 3. Abstract- Data from the Medical Record a. Abstraction Worksheet 2010 Intersect Healthcare, Inc. 25 Abstraction Worksheet 1. Is there an inpatient admission order for the initial date of service? Yes/No 2. What are the documented reasons for admitting the patient to inpatient care? 3. On the attestation statement is there a change in the working diagnosis to the principal diagnosis? Yes/No 4. What is the principal diagnosis billed on the claim? 5. Is this the same principal diagnosis assigned to the medical record? Yes/No 6. Was the patient transferred from another acute care facility on mechanical ventilation? Yes/No 7. Length of stay: ____________________ 8. What is the documented diagnosis for patient to be on mechanical ventilation? 9. Is there any laboratory values to support? ABG’s Yes/No 10. 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 g / y 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 11. Where there any test that revealed any Malignant conditions? Yes/No 2010 Intersect Healthcare, Inc. 26 13
  14. 14. Abstraction Worksheet Cont’d 12. Was treatment during stay directed at the Malignant conditions? Yes or No 13. Were there any complications noted during stay? Yes or No 14. Date and time if applicable of endotracheal intubation or tracheostomy for ventilation: ________________________________________________________ Was this patient transferred to this institution on mechanical ventilation? Yes or No Was patient discharged or transferred while intubated: _____________________ If applicable date and time patient was extubated:_________________________ Was ET or Tracheostomy performed in inpatient status? ____________________ Date and time mechanical ventilation was initiated? _______________________ Was patient weaned during time on the vent? If so hours___________________ Date and time mechanical ventilation ended:_____________________________ Was the patient completely weaned off the vent, and restarted within any time frame during the same admission? Yes or No, If applicable list dates______________________ 15. Is there any evidence in the medical record that the patient was only intubated for a procedure? Yes/No 16. Is there any evidence in the medical record that the ventilation is due to postoperative complications? 17. Was the patient diagnosed with any type of Respiratory Failure? Yes/No If so; Date and time and list any applicable testing that led to diagnosis __________________________________ 18. Was the patient admitted with Respiratory failure or did it develop after admission? Yes/No 2010 Intersect Healthcare, Inc. 27 Process Steps to Auditing the Medical Record 4. Code - Reviewer will code from data that they abstracted 5. Compare - Codes they assign to the codes that were billed 6. Identify - Any areas in the medical record for areas of uncertainty and discrepancies 7. Track Data Collected- Highlight areas, photocopy areas in question to possibly highlight for physician 8. Query - The provider on any discrepancies found. Send them the highlighted p g g portions of the medical record so that they can view. DO not lead .. Only identify what is in the record and ask for clarification a. Statement of Issue or Discrepancy b. Date Initiated c. Contact person and Info d. Date Query Completed 2010 Intersect Healthcare, Inc. 28 14
  15. 15. The Story Principal Diagnosis Documentation to support Secondary Diagnosis Procedures MS-DRG 2010 Intersect Healthcare, Inc. 29 Learning Objectives Ensure there is documentation in the medical record to support assigning a principal diagnosis within MDC 4 Ensure that there is a definitive diagnosis that affects or will affect the respiratory system to initiate – INVASIVE MECHANICAL VENTILATION (i.e. surgery, respiratory failure, and etc.) Be bl t t B able to track the time that mechanical ventilation is k th ti th t h i l til ti i initiated to the time that it ends within the institution Know the difference between Invasive and Non-Invasive Ventilation 2010 Intersect Healthcare, Inc. 30 15
  16. 16. Coding Clinics Intubation / Mechanical Ventilation /Respiratory Failure Absence of intubation and mechanical ventilation does not preclude the use of a diagnosis of respiratory failure, 518.8x. (See Coding Clinic, third quarter 1988, page 7.) Respirator Dependence Code 46.1, other dependence of machines, respirator, was expanded 10/1/2004. Code46.11, dependence on respirator, 10/1/2004 Code46 11 respirator status, is only used if there are no complications or malfunctions of respirator and is always a secondary code. Code 46.12, encounter for respirator dependence during power failure, can only be a principal or first-listed code. (DRG 467) (See Coding Clinic, fourth quarter 2004, pages 100 and 101.) 2010 Intersect Healthcare, Inc. 31 Coding Clinics Sequencing of respiratory failure in association with respiratory conditions. The sequencing depends on the reason for admission. When respiratory failure due to an underlying respiratory condition is the reason for the admission, the respiratory failure is the principal diagnosis. When the respiratory failure develops after admission, it is a secondary diagnosis. When a patient is admitted due to respiratory failure and pneumonia, the respiratory failure is sequenced first. These conditions are not co-equal. The guideline regarding two or more interrelated conditions meeting the definition of principal diagnosis does not apply, since this has been specifically addressed in separate Coding Clinic instructions. g (See Coding Clinic, first quarter 2005, pages 3-8, and Coding Clinic, second quarter 2003, pages 21 and 22; Coding Clinic, second quarter 2000, page 21; Coding Clinic, second quarter 1991, pages 3-5; and Coding Clinic, November- December 1987, pages 5 and 6.) 2010 Intersect Healthcare, Inc. 32 16
  17. 17. References HTTP://LIBRARY.AHIMA.ORG/XPEDIO/GROUPS/PUBLIC/DOCUMENTS/AHIMA/BOK1_043474.HCSP?D DOCNAME=BOK1_043474 HTTP://WWW.COMPLIANCECONCEPTS.COM/PRESSROOM/UNCOVERINGTHEMYSTERYBEHINDTHERA CCOMPLEXCODINGREVIEWS.ASP HTTP://WWW.PEPPERRESOURCES.ORG/LINKCLICK.ASPX?FILETICKET=RK7HAMWQYTU%3D&TABID=7 5&MID=416 2010 Intersect Healthcare, Inc. 33 Appealing a Respiratory System Diagnosis w/ Ventilator Support Denial Denise Wilson RRT, RN, MIS Director, Client Education  and Performance Improvement and Performance Improvement Intersect Healthcare, Inc. 17
  18. 18. Learning Objectives • Understand how to create a successful coding or medical necessity appeal for Respiratory System Diagnoses by: – Understanding the issue at hand – Providing a ‘Road Map’ for the reviewer – Presenting a Preponderance of Evidence • (Best Practice, Regulatory and CMS Guidelines) • Understand how to tailor appeals to the Administrative Law Judge 2010 Intersect Healthcare, Inc. 35 Understanding the Issue at Hand OIG Report on DRG 475 released December  1998 – (DRG 475 is now MS‐DRG 207, 208) DRG 475 was top 5% of DRGs in terms of  relative weight relative weight – http://oig.hhs.gov/oei/reports/oei‐03‐98‐ 00560.pdf 2010 Intersect Healthcare, Inc. 36 18
  19. 19. Understanding the Issue at Hand In 1996, it was estimated that 7% of DRG 475  should have been coded to a lower weight DRG should have been coded to a lower weight DRG In 1996,  Approximately $10,000 difference per  case, or $11.5 million DRG 475 vs. DRG 127 Heart Failure and Shock High Relative Weight and vulnerable to upcoding 2010 Intersect Healthcare, Inc. 37 Trending DRG Discharges Department of Health and  Human Services, Office of  Inspector General,  Medicare Payments for  DRG 475 Respiratory System  Diagnosis with Ventilator  Support, December 1998 OEI‐03‐98‐00560  http://oig.hhs.gov/oei /reports/oei-03-98- 00560.pdf 2010 Intersect Healthcare, Inc. 38 19
  20. 20. Planning for Appeals Considerations for Deciding to Appeal – Cost – Time – Resources – Chance of Overturn First Things First Planning – Return on Investment In addition to: – Root Cause Analysis – Education/Remediation Plan 2010 Intersect Healthcare, Inc. 39 Building the Foundation Close examination of decision letter – What are the instructions for appeal? – What forms do I need? – Where do I send my appeal? – What was the issue? Create Appeal Letter Templates 2010 Intersect Healthcare, Inc. 40 20
  21. 21. Building the Foundation http://racb.cgi.com/Issues.aspx 2010 Intersect Healthcare, Inc. Copyright 2009 5 41 Creating the Structure Paint the Picture – Comorbidities and Complications (CC or MCC) – Medical Complexity Provide a Road Map – Where is the Documentation? Write to the ALJ – Best chance of overturn Provide a Preponderance of Evidence 2010 Intersect Healthcare, Inc. Copyright 2009 4 42 21
  22. 22. Creating the Structure Use the Best Evidence – CMS Internet Only Manuals (IOM) – National Coverage Determinations; Local Coverage Determinations – ICD-9-CM Official Coding Guidelines – Coding Clinics First Things First Planning – Code of Federal Regulations (CFR) – Social Security Act – Evidence Based Guidelines, Position Statements, Expert Opinions from National Medical Associations 2010 Intersect Healthcare, Inc. Copyright 2009 5 43 Providing a Road Map 2010 Intersect Healthcare, Inc. 44 22
  23. 23. Providing a Road Map http://www.ama‐ assn.org/ama1/pub/upload /mm/362/icd9cm_coding_g /mm/362/icd9cm coding g uidelines_08_09_full.pdf 2010 Intersect Healthcare, Inc. 45 Providing a Road Map ICD-9-CM TABULAR LIST OF PROCEDURES (FY10) 96.7 Other continuous invasive mechanical ventilation Includes: BiPAP delivered through endotracheal tube or tracheostomy (invasive interface)… Excludes: non invasive bi level positive airway pressure [BiPAP] (93 90) non-invasive bi-level (93.90)…. Note: Endotracheal Intubation To calculate the number of hours (duration) of continuous mechanical ventilation during a hospitalization, begin the count from the start of the (endotracheal) intubation. The duration ends with (endotracheal) extubation. Tracheostomy To calculate the number of hours of continuous mechanical ventilation during a hospitalization, begin counting the duration when mechanical ventilation is started. The duration ends when the mechanical ventilator is turned off (after the weaning period). 96.70 Continuous invasive mechanical ventilation of unspecified duration Invasive mechanical ventilation NOS 96.71 Continuous invasive mechanical ventilation for less than 96 consecutive hours 96.72 Continuous invasive mechanical ventilation for 96 consecutive hours or more 2010 Intersect Healthcare, Inc. 46 23
  24. 24. Providing a Road Map 2010 Intersect Healthcare, Inc. 47 Providing a Road Map 2010 Intersect Healthcare, Inc. 48 24
  25. 25. Preponderance of Evidence • Indications for Mechanical Ventilation – http://www.merck.com – Indications: There are numerous indications for endotracheal intubation and mechanical ventilation but, in general, mechanical ventilation should be considered when there are clinical or laboratory signs that the patient cannot maintain an airway or adequate oxygenation or ventilation. Concerning findings include respiratory rate > 30/min, inability to maintain arterial O2 saturation > 90% with fractional inspired O2 (Fio2) > 0.60, and PaCO2 of > 50 mm Hg with pH < 7.25. The decision to initiate mechanical ventilation should be based on clinical judgment that considers the entire clinical situation and should not be delayed until the patient is in extremis. • Last full review/revision August 2007 by Brian K. Gehlbach, MD; Jesse Hall, MD • Content last modified August 2007 2010 Intersect Healthcare, Inc. Copyright 2009 17 49 Preponderance of Evidence Guidelines on the Management of Community-Acquired Pneumonia in Adults – Time to First Antibiotic Dose • For patients admitted through the emergency department (ED), the first antibiotic dose should be administered while still in the ED. (Moderate recommendation; level III evidence) – Switch from Intravenous to Oral Therapy • Patients should be switched from intravenous to oral therapy when they are hemodynamically stable and improving clinically, are able to ingest medications, and have a normally functioning gastrointestinal tract. (Strong recommendation; level II evidence) – Duration of Antibiotic Therapy • Patients with CAP should be treated for a minimum of 5 days (level I evidence), should be afebrile for 48 to 72 h, and should have no more than 1 CAP CAP-associated sign of clinical i i d i f li i l instability ( bili (see T bl b l ) b f Table below) before discontinuation of therapy. (level II evidence) (Moderate recommendation) Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community‐acquired  pneumonia in adults. Mandell LA, et.al; Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community‐ acquired pneumonia in adults. Clin Infect Dis 2007 Mar 1;44 Suppl 2:S27‐72. [335 references] PubMed http://www.guidelines.gov 2010 Intersect Healthcare, Inc. Copyright 2009 17 50 25
  26. 26. Capping the Issue Use guidelines in place at the time care was provided Include an Attachments List Include all Attachments Electronic Copy First Things First Planning Use a Document Editor to Highlight the Medical Record Send all Communication via a Traceable Method 2010 Intersect Healthcare, Inc. 51 26

×