slide 1 - virginia health information management association
TRANSCRIPT
MS-DRGs – The First Six Months Update
April 2008
Virginia HIMA Annual Convention
Melinda S. Stegman, MBA, CCS
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Agenda – MS-DRGs
Brief overview
New concepts introduced with MS-DRGs
Conditional MCCs
MCCs and CCs excluded by DRG definition
Procedure Proxies
Undocumented changes, inconsistencies and what really happened (MDCs 03 and 09)
Relative Weight issues
Potential overcoding (maximizing): Beware
MS-DRGs and RAC Issues
Conclusions
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MS-DRG Basics
Officially named MS-DRGs (Medicare Severity) Built on CMS DRGs (similar subgroups) 745 final DRGs numbered from 001 to 999 Explanation of variance in consumed hospital resources
increased over previous DRGs by 9.41% Major overhaul of previous CCs 1, 2 and 3-way splits based on CC or MCC
With MCC, with CC or without CC/MCC (e.g. concussion, major chest procedures)
With CC/MCC or without CC/MCC (e.g. bronchitis or asthma) With MCC or without MCC (e.g. seizures, headaches) No splits (e.g. angina pectoris, chest pain)
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Conditional MCCs
Certain MCCs are excluded from list unless the patient is discharged alive 427.41(ventricular fibrillation)
427.5 (cardiac arrest)
785.51 (cardiogenic shock)
785.59 (other shock without mention of trauma)
799.1 (respiratory arrest)
If the patient expires, the conditions above are considered non-CCs
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MCCs and CCs Excluded by DRG Definition
Many MS DRGs use secondary diagnoses as part of the DRG definition E.g.: MS DRG 280/281/282 AMI, Discharged Alive
– Must have principal dx in MDC 05, any dx of AMI Initial Episode
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) 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.
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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 DxsMS-DRG
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MCC/CC Capture Rates
CMS has estimated that MCC/CC Capture Rates would decrease to approximately 40% nationally.
Does your facility calculate MCC/CC Capture Rates on a routine on-going basis?
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Procedures Used as “Proxy” for MCC/CCs
DRG 024 Craniotomy w major device … w/o MCC ==>DRG 023 Craniotomy w major device… w MCC or chemo implantwith 00.10 (implantation of chemotherapeutic agent)
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
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
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)
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Procedures Used as “Proxy” for MCC/CCs
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)
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
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
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Procedures Used as “Proxy” for MCC/CCs
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
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)
DRG 006 Liver transplant w/o MCC ==> DRG 005 Liver transplant w MCC or intestinal transplant with 46.97 (Transplant of intestine)
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Undocumented Changes & Inconsistencies by CMS
Inconsistencies in CMS documentation Table F (Final Rule; Federal Register; Vol. 72,
No. 162, August 22, 2007, page 47156) CMS-DRG to MS-DRG crosswalk (both in
Proposed Rule and Final Rule)
YesSkin Graft and Debridement
CMS DRG Model, MDC 9 - Diseases & Disorders Of The Skin, Subcutaneous Tissue & Breast (CMS-DRGs)
263
268
267Perianal and Pilonidal Cyst Procedures
Plastic Procedures
No
O.R.Procedure
2
Yes
No
S u r g ic a lP a r t it io n in g
PDX Skin Ulceror Cellulitis CC
Yes
No 264
CC
265
No 266
Yes
1
CMS DRG Model, MDC 9 - Diseases & Disorders Of The Skin, Subcutaneous Tissue & Breast (CMS-DRGs)
257
258
259
260
Total MastectomyMastectomy andAny DX of Breast
Malignancy
Yes
1
Yes
NoCC
Subtotal Mastectomy
Yes
NoCC
261
262
2 6 9
2 7 0
No
Breast without Biopsy and Local Excision
Breast Biopsy and Local Excision
Ye s
N o
C C , O t h e r S k in S u b c u t a n e o u s T is s u e a n d B r e a s t P r o c e d u r e s
Unrelated ORLogic
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MDC – 09 Surgical Hierarchy Under MS-DRGs
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MDC – 09 Surgical Hierarchy Under MS-DRGs
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Unintended Consequences
Procedures in V24 DRG 269, 270 have leapfrogged in the surgical hierarchy procedures in V24 DRGs 257-260
This means cases with the following procedures will take precedence OVER mastectomies: 86.09 – Skin & Subq Incision NEC 86.3 – Other Local Destruc Skin
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MDC 03 - What was Documented
The Final Rule:
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MDC 03 - What was Documented - Inconsistencies
CMS Crosswalk from CMS-DRGs to MS-DRGs:
063
062
061
060
059
058
057
056
Other ear, nose, mouth & throat O.R. procedures w/o CC/MCC134055
Other ear, nose, mouth & throat O.R. procedures w CC/MCC133S03052
Cranial/facial procedures w/o CC/MCC132
Cranial/facial procedures w CC/MCC131S03
CommentsMS-DRG Descriptions MS v25medsurgmdcCMS V24
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MDC 03 – What happened
049 - Major Head & Neck Procedures 129/130 - Major Head & Neck Procedures
061/062 – Myringotomy w Tube Insertion131/132 – 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
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MDC 03 – What happened
049 - Major Head & Neck Procedures 129/130 - Major Head & Neck Procedures
061/062 – Myringotomy w Tube Insertion131/132 – 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
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MDC 03 – What happened
049 - Major Head & Neck Procedures 129/130 - Major Head & Neck Procedures
061/062 – Myringotomy w Tube Insertion131/132 – 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
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MDC 03 – What happened
049 - Major Head & Neck Procedures 129/130 - Major Head & Neck Procedures
061/062 – Myringotomy w Tube Insertion131/132 – 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
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MDC 03 – What happened
049 - Major Head & Neck Procedures 129/130 - Major Head & Neck Procedures
061/062 – Myringotomy w Tube Insertion131/132 – 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
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MDC 03 – What happened
Procedure Codes from V24 DRG 055 in MS DRG 131/132 21.4 – Resection of the Nose 21.72 – Open Resection of Nasal Fracture
Procedure Codes from V24 DRG 063 in MS DRG 131/132 16.52 – Exenteration Orbit Therapeutic Removal Orbital Bone 16.98 - Other Operations on Orbit 76.01 – Sequestrectomy of Facial Bone wo Division 76.19 – Other Diagnostic Procedures on Facial Bones and Joints 76.2 – Local Excision or Destruction of Lesion of Facial Bone 76.39 – Partial Ostectomy of Other Facial Bone 76.43 – Other Reconstruction of Mandible 76.44 – Total Ostectomy of Other Facial Bone w Synchronous Reconstruction 76.45 – Other Total Ostectomy of Other Facial Bone 76.46 – Other Reconstruction of Other Facial Bone 76.61 – Closed Osteoplasty (Osteotomy) of Mandibular Ramus 76.62 – Open Osteoplasty (Osteotomy) of Mandibular Ramus 76.63 – Osteoplasty (Osteotomy) of Body of Mandible 76.64 – Other Orthognathic Surgery of Mandible
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MDC 03 – What happened
Procedure Codes from V24 DRG 063 in MS DRG 131/132 (con’t) 76.65 – Segmental Osteoplasty (Osteotomy) of Maxilla 76.66 – Total Osteoplasty (Osteotomy) of Maxilla 76.67 – Reduction Genioplasty 76.68 – Augmentation Genioplasty 76.69 – Other Facial Bone Repair 76.70 – Reduction of Facial Fracture, Not Otherwise Specified 76.72 – Open Reduction of Malar and Zygomatic Fracture 76.74 – Open Reduction of Maxillary Fracture 76.76 – Open Reduction of Mandibular Fracture 76.77 – Open Reduction of Alveolar Fracture 76.79 – Other Open Reduction of Facial Fracture 76.91 – Bone Graft to Facial Bone 76.92 – Insertion of Synthetic Implant in Facial Bone 76.94 – Open Reduction of Temporomandibular Dislocation 76.97 – Removal Internal Fixation Device Facial bone 76.99 – Other Operations on Facial Bones and Joints
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MDC 03 – What happened
Non MDC 03 Procedure Codes from V24 in MS DRG 131/132 01.23 – Craniotomy and Craniectomy; Reopening of Craniotomy Site 01.24 – Other Craniotomy 01.25 – Other Craniectomy 01.6 – Excision of Lesion of Skull 02.01 – Opening of Cranial Suture 02.02 – Elevation of Skull Fracture Fragments 02.03 – Formation of Cranial Bone Flap 02.04 – Bone Graft to Skull 02.05 – Insertion of Skull Plate 02.06 – Cranial Osteoplasty 02.07 – Removal of Skull Plate 02.99 – Other Operations on Skull, Brain, and Cerebral Meninges; Other 16.01 – Orbitotomy with Bone Flap 16.02 – Orbitotomy with Insertion of Orbital Implant 16.09 – Other Orbitotomy 16.51 – Exenteration of Orbit with Removal of Adjacent Structures 16.59 – Other Exenteration of Orbit 16.63 – Revision of Enucleation Socket with Graft 16.64 – Other Revision of Enucleation Socket 16.89 – Other Repair of Injury of Eyeball or Orbit 16.92 – Excision of Lesion of Orbit
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Relative Weights are NOT Consistent
DRGs based on medical knowledge should be higher in relative weight, are not necessarily: MS DRG 082 Traumatic Stupor and Coma, Coma > 1 hour with
MCC has a weight of 1.6724 MS DRG 085 Traumatic Stupor and Coma, Coma < 1 hour with
MCC has a weight of 1.6946
MS DRG 083 Traumatic Stupor and Coma, Coma > 1 hour with CC has a weight of 1.3328
MS DRG 086 Traumatic Stupor and Coma, Coma < 1 hour with CC has a weight of 1.2337
MS DRG 084 Traumatic Stupor and Coma, Coma > 1 hour without CC/MCC has a weight of 1.1106
MS DRG 087 Traumatic Stupor and Coma, Coma < 1 hour without CC/MCC has a weight of 0.9235
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Relative Weights are NOT Consistent
Like conditions don’t necessarily correspond to similar change in weights MS DRG 716 has a higher weight than MS DRG 718
– MS DRG 716 Other Male Rep. Sys. With PDX Malignancy without CC/MCC has a weight of 1.1310
– MS DRG 718 Other Male Rep. Sys. Without PDX Malignancy without CC/MCC has a weight of 1.0329
MS DRG 715 has a lower weight than MS DRG 717– MS DRG 715 Other Male Rep. Sys. With PDX Malignancy with
CC/MCC has a weight of 1.5300– MS DRG 717 Other Male Rep. Sys. Without PDX Malignancy
with CC/MCC has a weight of 1.5653
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Potential Overcoding Examples
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Potential Overcoding: Beware!
Number 1 high-dollar overcoded DRG subgroup: DRG 981 Extensive O.R. Procedure Unrelated to Principal
Diagnosis with MCC RW 4.5168 ($22,584) DRG 982 Extensive O.R. Procedure Unrelated to Principal
Diagnosis with CC RW 3.5417 ($17,709) DRG 983 Extensive O.R. Procedure Unrelated to Principal
Diagnosis without CC/MCC RW 2.9737 ($14,869)
Old DRG 468 FY07 RW 3.9880 ($19,940) Issue: what is the definition of principal diagnosis? Co-existing principal diagnoses: was the patient really
admitted for the treatment of BOTH conditions?
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Potential Overcoding: Beware!
Sequencing issues: 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.
What is the principal diagnosis?
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Potential Overcoding: Beware!
Prior to 10/1/07, sequencing pneumonia first was best financially.
Since MS-DRGs include subgroups for COPD, the highest weighted one (with MCC) carries a higher RW than the simple pneumonia DRG.
BUT…don’t forget the sequencing rules. The patient was really admitted for pneumonia, which caused the COPD exacerbation.
For FY07For 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
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Potential Overcoding: Beware!
Infectious Diseases Don’t infer that any positive culture means a systemic
infection– Contaminants (such as staph epidermis)– Localized superficial infections (such as oral thrush
causing a positive yeast culture)– Look at the entire clinical picture
– Treatment options (extended IV antibiotics or anti-fungals)
– Length of stay
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Potential Overcoding: Beware!
Sepsis Do not code sepsis based on ONE progress note or
other mention in the documentation; it may have been considered a “rule-out” condition.
“Urosepsis” still codes to urinary tract infection “Line sepsis”
– Code 996.62 Infection/inflammatory reaction due to other vascular device, implant and graft should be PDX
– See Coding Clinic, 2nd Quarter 2004, page 16:– 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.
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Potential Overcoding: Beware!
Malnutrition May be due to insufficient intake, increased loss, increased
demand, or a condition that decreases the body’s ability to digest and absorb nutrients.
MCCs include:– 260 Kwashiorkor (not typically seen in U.S. hospitals)– 261 Nutritional marasmus– 262 Other severe, protein-calorie malnutrition
CCs include:– 263.2 Arrested development following protein-calorie malnutrition– 263.8 Other protein-calorie malnutrition– 263.9 Unspecified protein-calorie malnutrition
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Potential Overcoding: Beware!
Malnutrition Do not assign these codes based on documentation of
“unexpected weight loss” alone Look for in patients with:
– Chronic conditions: short-gut syndrome, GI infectious processes, GI malignancies, malabsorption syndromes: (celiac disease, cystic fibrosis, pancreatic insufficiency, Crohn’s disease, pernicious anemia)
– Acute conditions: severe burns, infection, surgery, trauma Measurable substantiation must be present in the record:
– Total protein (A/G Ratio)– Hemoglobin– Albumin– Vitamin deficiency
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Potential Overcoding: Beware!
Mechanical ventilation 96.70 Continuous mechanical ventilation for unspec duration 96.71 Continuous mechanical ventilation for < 96 hours 96.72 Continuous mechanical ventilation for > 96 hours
Do NOT assign these codes for: CPAP or BiPAP delivered through tracheostomy
– Forms of respiratory assistance– Augments the patient’s own breathing
Refer to Coding Clinic, 1st Quarter 2008, pages 8-9 Be sure to review your Ventilation forms in the record;
ensure that CPAP & BiPAP are differentiated
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Potential Overcoding: Beware!
Mechanical ventilation High-dollar DRG risk area All other medical MDC 4
DRGs have an average RW of 1.1255 ($5,628)
These DRGs are under scrutiny by RACs, other government auditors
All MS-DRGs 207 & 208 should be routinely reviewed internally
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 207MS-DRG 208
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Potential Overcoding: Beware!
Coagulopathy PDX documented as “Coumadin-induced coagulopathy” Some coders have been assigning:
– PDX: 286.5 Hemorrhagic disorder due to intrinsic circulating anticoagulants
– SDX: 578.X GI bleeding; 784.7 Epistaxis; 599.7 Hematuria; 786.3 Hemoptysis
“Coumadin-induced” means that this was either an adverse reaction or a poisoning
– Adverse reaction: sequence the bleeding condition as PDX– Adverse reaction: sequence the adverse reaction (E934.2) as SDX– Poisoning: sequence the poisoning (964.2) as PDX– Poisoning: sequence the bleeding as SDX
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Potential Overcoding: Beware!
Coagulopathy Refer to Coding Clinic, 3rd Quarter 2004, page 7 Don’t forget other helpful codes for Coumadin-related conditions
– 790.92 Abnormal coagulation profile– V58.61 Long-term (current) use of anticoagulants
Coumadin
PoisoningHemoptysisHematuriaEpistaxisGI BleedingCoagulopathy
$3,443$3,329$3,138$3,114$5,098$6,713
RW: 0.6886RW: 0.6658RW: 0.6276RW: 0.6227RW: 1.0195RW: 1.3426
PDX: 964.2PDX: 786.3PDX: 599.7PDX: 784.7PDX: 578.9PDX: 286.5
MS-DRG 918MS-DRG 204MS-DRG 696MS-DRG 151MS-DRG 378MS-DRG 813
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Potential Overcoding: Beware!
Debridement Differentiation of excisional and non-excisional is required
– 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
– Non-excisional (86.28): non-operative brushing, irrigating, scrubbing or washing away of devitalized tissue, necrosis or slough; may include whirlpool debridement
The problem is usually in the documentation (or lack thereof)– “Sharp” is not sufficient for excisional– The use of scissors does not necessarily equate to excisional
An excisional debridement may be performed by a nurse, therapist, physician assistant or a physician (Coding Clinic, 2nd Quarter 2000, page 9)
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Potential Overcoding: Beware!
Debridement Procedural details should be documented:
– Instruments used– Extent and depth of the procedure– Definite cutting away of tissue
Excisional debridement should NOT be assigned if performed as a part of the following procedures:
– Incision and drainage– Bursectomy– Amputation
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Potential Overcoding: Beware!
Debridement For excisional debridements, the code assigned should reflect
the deepest layer of tissue debrided– Fascia– Muscle– Bone
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.
– E.g., for excisional debridement of soft tissue– Excision, lesion
soft tissue NEC 83.39– Refer to Coding Clinic, 2nd Quarter 2006, pages 3-4
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Potential Overcoding: Beware!
Debridement In some cases, the questions related to depth
of debridement may relate the patient’s diagnosis.
– Necrotizing fasciitis -- Was fascia debrided?– Osteomyelitis – Was muscle, fascia or bone
debrided?– Decubitus ulcer – Was muscle or fascia debrided?– Complicated wound – Was muscle, fascia, tendon,
bursa or bone debrided?
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Potential Overcoding: Beware!
Debridement Coding Clinic, 1st Quarter 2008, page 3
– Must excisional debridement involve cutting outside or beyond the wound margin? Does the documentation specifically need to state this?
– “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.”
– Some review organizations (including RACs) were interpreting the “must involve cutting outside or beyond the wound margin” literally.
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Other RAC (MS-DRG) Related Target Issues
Single CC/MCC DRGs Major bowel procedures
– MS-DRG 330 Major small & large bowel procedures with CC– PDX of malignant neoplasm of intestine (15X.X)
– SDX (and only CC) of lymph node metastasis (196.X)
– PDX of diverticulitis (562.11)– SDX (and only CC) of abscess of intestine (569.5)
Issue: RAC is looking for diagnoses documented ONLY on pathology report
– Some coders are coding 569.5 for “microperforations” or “microabscesses” on pathology report. These are present in nearly ALL diverticulitis cases.
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Other RAC (MS-DRG) Related Target Issues
Single CC/MCC DRGs Issue: RAC is looking for diagnoses documented ONLY on
pathology report See Coding Clinic, 1st Quarter 2004, page 20:
“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.”
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Other RAC (MS-DRG) Related Target Issues
Single CC/MCC DRGs Acute blood loss anemia (285.1) assigned as only CC for hip ORIF and
other related procedures Moves MS-DRG from 482 to 481 Hip & Femur Procedures Except Major
Joint (without and with CC) Refer to Coding Clinic, 1st Quarter 2007, page 19When 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:
Anemia postoperative due to blood loss 285.1 other 285.9
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Conclusions
Yes, MS-DRGs are similar to the old CMS-DRGs but we have different issues 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.
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.
The learning curve will improve and productivity may also, although possibly not back to pre-MS-DRG levels.
Ensure each condition addressed/treated is coded, but don’t overmaximize – Coding Clinic still rules.
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Conclusions
Most facilities are seeing: Increase in:
– Accounts Receivable (AR) dollars– Average time required to code an inpatient record– Number of physician queries required to code adequately and
completely for MS-DRGs– Need for physician education re: documentation specificity
Still to be determined:– Impact on CMI; this will largely be determined by size of facility and
types of services provided– Whether CMS’ idea of the need for a “behavioral offset” was
legitimate
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Conclusions
What everyone should be doing: Data mining; if the RACs, QIOs and other government agencies
are looking at your data, you should be too!– Start with some of the potential overcoding issues identified here– Track progress over time– Use public databases from the existing Payment Error Programs
– Hospital Payment Monitoring Program (HPMP)– Medicare inpatient cases– Previously called the Payment Error Prevention Program (PEPP)– Reviews that are performed by the QIOs– Monitor your Program for Evaluating Payment Patterns Electronic
Report (PEPPER)
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Questions?
It’s an exciting time in HIM, with MS-DRGs, POA, RACs, MACs, etc.
Please contact me if you wish –