MS-DRG 207 slides

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

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

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


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!

3

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.


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


4

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


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


5

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


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


6

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.


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.


7

When in Doubt…

Refer to Coding Clinics

Query, query, query!


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

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

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.


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


10

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


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


11

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

Auditing to tell the Story
Examine

Query Review

Track
Documentation Abstract
Data

Identify Code

Compare

12

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


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


13

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


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


14

The Story

Principal Diagnosis Documentation to support Secondary Diagnosis Procedures MS-DRG


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


15

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.)


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.)


16

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


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

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


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


18

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

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


19

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


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


20

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

42

21

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
– Code of Federal Regulations (CFR)
– Social Security Act
– Evidence Based Guidelines, Position Statements,
Expert Opinions from National Medical
Associations

43

Providing a Road Map


22

http://www.ama‐
assn.org/ama1/pub/upload
/mm/362/icd9cm_coding_g
/mm/362/icd9cm coding g
uidelines_08_09_full.pdf


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


23





24

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

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

50

25

Capping the Issue
Use guidelines in place at the time care was provided

Include an Attachments List

Include all Attachments
Electronic Copy
Use a Document Editor to Highlight the Medical
Record

Send all Communication via a Traceable Method


26

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