1. 2010 UBO/UBU Conference Health Budgets & Financial Policy 111 Briefing: Common Coding Pitfalls Impacting MS-DRGs Date: 24 March 2010 Time: 1300–1350

2. 2010 UBO/UBU Conference Turning Knowledge Into Action 22 Objectives Foster greater understanding about MS-DRGs – Background – Weighted value (TRICARE) Identify Common Coding Pitfalls Discuss Rescue Attempts Summation

3. 2010 UBO/UBU Conference Turning Knowledge Into Action 3 MS-DRGs Background Military Health System (MHS) adopted the Medicare Severity-DRGs effective 1 October 2008 (FY09). TRICARE/CHAMPUS DRG uses – MS-DRG logic – MS-DRG assignment for SIDR DoD assigned weights http://www.tricare.mil/drgrates/ – TRICARE MS-DRG

4. 2010 UBO/UBU Conference Turning Knowledge Into Action 44 MS-DRGs Background (cont’d) Evolution brought change and new terminology. – Increased number of DRGs – Revised CC listing – Created MCCs – Hospital-Acquired Conditions (HACs) – Present on Admission (POA) indicator Under the MS-DRGs, the severity of a patient’s illness must be more accurately documented in order for the hospital to be reimbursed appropriately for the care provided. 4

5. 2010 UBO/UBU Conference Turning Knowledge Into Action 55 MS-DRG Terminology MS-DRG: Medicare Severity-Based Diagnosis Related Groups Complexity: Differences in resource needs that are not diagnosis-related – Heart assist devices – Organ transplants – Bone marrow transplants – Tracheostomy CC: A secondary diagnosis determined to be a complication or co-morbidity in relationship to the principal diagnosis MCC: A secondary diagnosis determined to be a complication or co-morbidity which exceeds the resource use of the standard CC

6. 2010 UBO/UBU Conference Turning Knowledge Into Action 66 DRGs vs. MS-DRGs DRGs split – Age – With CC – Without CC MS-DRGs split – Tiers – Presence or absence of CC – If present, is CC “major” (MCC) or not? – Could result in up to three tiers of payment Absence of CC Presence of CC Presence of MCC 6

7. 2010 UBO/UBU Conference Turning Knowledge Into Action 77 MS-DRGs – Assignment to Severity Tiers  Severity and weight increase with each tier  Severity tier depends on secondary diagnosis MS-DRG DescriptionWeight (FY10) 291 Heart Failure and shock w/MCC1.4872 292 Heart Failure and shock w/CC 0.9164 293 Heart Failure and shock w/o CC/MCC 0.7176 If none of the secondary diagnoses codes are MCCs or CCs, the MS-DRG w/o CC/MCC is assigned. MCCs take precedence over CCs. Only one CC or MCC code is needed for assignment to a specific MS-DRG. BUT, DON’T STOP there!

8. 2010 UBO/UBU Conference Turning Knowledge Into Action 8 Initial Split: TRICARE MS-DRG in 2009 014Intracranial Hemorrhage or Cerebral Infarction 1.3807 064Intracranial Hemorrhage or Cerebral Infarction w/MCC 2.4223 065Intracranial Hemorrhage or Cerebral Infarction w/CC 1.3422 066Intracranial Hemorrhage or Cerebral Infarction w/o CC/MCC 1.0291 8 FY09 Note: Comparison is FY08 DRG w/ FY09 MS-DRG. FY08

9. 2010 UBO/UBU Conference Turning Knowledge Into Action 9 Initial Split: TRICARE MS-DRG (cont’d) 127Heart Failure and Shock 1.0292 291Heart Failure and Shock w/MCC 1.4248 292Heart Failure and Shock w/CC 0.9638 293Heart Failure and Shock w/o CC/MCC 0.6815 9 NEW Note: Comparison is FY08 DRG w/ FY09 MS-DRG. FY08

10. 2010 UBO/UBU Conference Turning Knowledge Into Action 10 TRICARE MS-DRG 2008 / 2009 / 2010 078Pulmonary Embolism 1.1580 175Pulmonary Embolism w/ MCC 1.56591.3731 176Pulmonary Embolism w/o MCC 1.00130.9910 10 NEW Notice adjustment from FY09 to FY10 FY08 FY09 FY10

11. 2010 UBO/UBU Conference Turning Knowledge Into Action 11 TRICARE MS-DRG 2008 / 2009 / 2010 103Heart Transplant or Implant of Heart Assist System 21.2217 001Heart Transplant or Implant of Heart Assist System w/MCC 31.238523.1022 002Heart Transplant or Implant of Heart Assist System w/o MCC 12.405615.8832 11 NE W Notice adjustment from FY09 to FY10 FY08 FY09 FY10

12. 2010 UBO/UBU Conference Turning Knowledge Into Action 12 How DRGs 079, 080, & 081 Changed 177Respiratory infections and inflammations w/MCC 2.40992.3302 178Respiratory infections and inflammations w/CC 1.71191.8230 179Respiratory infections and inflammations w/o CC/MCC 1.17991.0813 12 MS-DRGs FY0 9 FY1 0

13. 2010 UBO/UBU Conference Turning Knowledge Into Action 13 Common Coding Pitfalls Lack of Documentation Lack of Granularity (in data) Decrease in Case Mix Index (severity) Wrong POA Indicator Loss of Revenue

14. 2010 UBO/UBU Conference Turning Knowledge Into Action 14 Pitfall – Lack of Documentation Scenario: Patient admitted with abdominal pain and melena. Repeat lab shows precipitous drop in Hct. Discussion: – Melena (578.1 or 562.xx [GI tract, unsp/diverticulosis/ diverticulitis]) – could be CC/MCC – No documentation re: precipitous drop in Hct – Is CC/MCC missing? – Could it be anemia? Chronic blood loss (unspecified) – No CC or MCC Acute post-hemorrhagic anemia – CC Diagnostic Findings – Lab and other ancillary tests – Biopsies Only one CC or MCC needed …BUT, DON’T STOP there!

15. 2010 UBO/UBU Conference Turning Knowledge Into Action 15 Rescue Fact: precipitous drop in Hct Was there blood loss? Was there an impact due to blood loss? Was there treatment for possible blood loss? Is it associated w/the melena? Is drop in Hct indicative of another condition? – Is it anemia? – Other blood dyscrasia? 15 Rescue: Query the physician

16. 2010 UBO/UBU Conference Turning Knowledge Into Action 16 Pitfall – Documentation of Neonatal Codes Scenarios: Physician uses both Transient Tachypnea of the Newborn (TTN) and Respiratory Distress Syndrome (RDS) in the baby’s chart, AND Physician does not clearly explain (at discharge) which is correct, OR Continuous Positive Airway Pressure (CPAP) or high nasal cannula (HFNC) used for > 24 hours

17. 2010 UBO/UBU Conference Turning Knowledge Into Action 17 Neonatal Codes (cont’d) “The American Hospital Association’s Coding Clinic from November-December 1986 initially separated RDS into type 1 (coded to 769) and type 2 or TTN (code 770.6). It further stated that the type 2 version was also referred to as mild and commented that recovery was generally made by the third day of life. Confusion continued, however, and the first quarter 1989 issue of Coding Clinic added that the two conditions were mutually exclusive: The coder was allowed to apply only one of the diagnoses. The explanation continued that the tabular instructions with each code excluded the other, and RDS includes clinical symptoms of tachypnea. It further added that the milder diagnosis of TTN ‘by definition resolves within 6 to 24 hours of birth.’ … Even physicians themselves have trouble reaching a consensus about when the problem constitutes RDS and when the symptoms are representative of the less severe diagnosis of TTN…If neither the payers nor the doctors can agree on what constitutes a valid RDS diagnosis, how are coders supposed to figure it out?” Reference: “Dealing With Fussy Neonatal Codes” For the Record, October 13, 2008. 17 Excerpt…

18. 2010 UBO/UBU Conference Turning Knowledge Into Action 18 Rescue Discussion: If documentation in chart is TTN, there are no significant CXR findings, the baby makes a speedy recovery, there was no O2 or face mask was used for a few hours only – TTN code is appropriate. OR, If baby is preterm, CXR shows significant findings and requires Rx for resolution, gets CPAP or other mechanical ventilation for > 24 hrs, and documentation = hyaline membrane disease or RDS, the code 769 would be appropriate. BUT, If discharge note shows mild RDS or hyaline membrane disease, or the physician uses both RDS & TTN in the note, or not in the note but in the same chart, and never clearly states which was correct … 18 RESCUE: Query the provider Do Not Guess Risk and Reimbur$ement at stake Coder not clinically qualified re: final diagnosis.

19. 2010 UBO/UBU Conference Turning Knowledge Into Action 19 Pitfall and Rescue Pitfall: Not staying abreast of coding changes Pitfall: Not establishing a working relationship with providers Pitfall: Not optimizing reimbursement opportunities New Major Complications and Comorbidities (MCC) for current fiscal year. 277.88 Tumor lysis syndrome 670.22 Puerperal sepsis (delivered w/postpartum complication) 670.24 Puerperal sepsis (postpartum condition/complication) 670.32 Puerperal septic thrombophlebitis (delivered w/postpartum complication) 670.34 Puerperal septic thrombophlebitis (postpartum condition/complication) 670.80 Other major puerperal infection (unspecified episode or N/A) 670.82 Other major puerperal infection (delivered w/postpartum complication) 670.84 Other major puerperal infection (postpartum condition/complication) 756.72 Omphalocele 756.73 Gastroschisis 768.73 Severe hypoxic-ischemic encephalopathy 779.32 Bilious vomiting in newborn 19 Rescue: Read! Read! Read! Could the CC be a MCC? Capitalize on educational opportunities!

20. 2010 UBO/UBU Conference Turning Knowledge Into Action 20 Pitfalls and Rescue Pitfall: Inadequate Physician Documentation Pitfall: Lack of Specificity Pitfall: Lack of granularity ●In general ●4 th and 5 th level of the ICD-9-CM code ●Did you read through all pertinent documents when coding the record? ●Discharge Summary/Note ●History/Physical (H/P) Examination ●Operation/Pathology Report ●Did you look for “details” in the ancillary notes/reports? ●Did you follow up on problems? ●Focused audits ●Educating the providers 20 Rescue: More Adjectives!

21. 2010 UBO/UBU Conference Turning Knowledge Into Action 21 Pitfall – Decrease in Case Mix Index (CMI) Pitfall: Not knowing coding trends Pitfall: Not knowing case mix Pitfall: Not capturing appropriate level of severity Pitfall: Not using appropriate secondary diagnoses Pitfall: Not getting appropriate reimbur$ement Pitfall: Not getting accurate record of patient care 21

22. 2010 UBO/UBU Conference Turning Knowledge Into Action 22 Rescue Rescue: ●Monitor coding pattern changes ●Don’t ignore the “specifics” in the documentation (including ancillary notes/reports) ●Code all significant conditions (CC/MCC)/surgery ●Results ●Increase in hospital resources for ●Treatment of acute disease ●Treatment of chronic diseases (advanced, exacerbated, or associated with extensive disability) ●Accurate reimbursement 22 A true picture of how sick your patients are…

23. 2010 UBO/UBU Conference Turning Knowledge Into Action 23 Rescue (cont’d) Rescue: ●Implement Clinical Documentation Improvement (CDI) plan ●Education (coders/providers) ●All rescue plans activated… ●Accurate record of patient care ●Appropriate reimbur$ement ●Accurate CMI and severity ●It’s your MTF’s report card! 23

24. 2010 UBO/UBU Conference Turning Knowledge Into Action Rescue (cont’d) Compute CMI for your MTF for specified time frame CMI = average cost weight for all discharges Example: - Total RWPs = 12,450 - 9,575 discharges - CMI = (12,450/9575) = 1.3003 Many factors – Classification system used – Statistical methodologies, etc. – +/- “outliers” Baseline and Trend Severity (CMI) 24 Sum of RWPs of all patients discharged Divided by number of discharges (patients)

25. 2010 UBO/UBU Conference Turning Knowledge Into Action 25 Rescue (cont’d) 25 To run CM reports in CHCS: 1. After logging into CHCS, select ORM = Output Reports Menu 2. Select EOUT = Encoder-Grouper Output Menu 3. Select one of the reports below: 1 (460) No of Dispositions and Days Data by DRG 2 (461) Inputs Who Exceed DRG LOS 3 (462) No of Dispositions and Days Data by Category 4 (463) Records with DRGs 468, 469 or 470 5 (464) Case Mix Deviation from Expected Wt 6 (469) Patient Summary 7 (204) Clinical Records with Forced (Override) Flag 8 Batched Records Without DRGs 9 Final Diagnoses, Procedures, & DRG Report

26. 2010 UBO/UBU Conference Turning Knowledge Into Action 26 Rescue (cont’d) 26 DRG Analysis Report RWP DRG # of patients by DRG

27. 2010 UBO/UBU Conference Turning Knowledge Into Action 27 POA Indicators There are five POA indicators.  Y = Yes  N = No  U = Unknown (documentation insufficient)  W = Unable to determine if diagnosis was present at the time of admission  1 = Exempt, indicates specific code is on the exempt list

28. 2010 UBO/UBU Conference Turning Knowledge Into Action 28 Assessing POA Status Scenario: Patient develops “acute cystitis” 3 days into the hospitalization. Question: What is the POA indicator? Discussion: Although the MS-DRG assignment flags the cystitis as a “CC,” when it comes to reimbursement, payment will be re-calculated as if the cystitis were not present (no CC) and the case will be re- grouped to a different (lower paying) MS-DRG by the payer. 28 Is a query necessary? Perhaps the cystitis was present but not documented.

29. 2010 UBO/UBU Conference Turning Knowledge Into Action Assessing POA Status (cont’d) Scenario: Patient with Diabetes Mellitus developed uncontrolled diabetes on day 3 of the hospitalization. Question: What is the POA indicator? Discussion: Assign “Y” if all parts of the combination code were present on admission with diabetic nephropathy is admitted with uncontrolled diabetes). Assign “N” if any part of the combination code was not present on admission (e.g., obstructive chronic bronchitis w/acute exacerbation and the exacerbation was not present on admission; asthma patient develops status asthmaticus after admission). 29

30. 2010 UBO/UBU Conference Turning Knowledge Into Action 30 Analyzing a Diagnosis for POA Status 30 Scenario: During hospital stay diabetes became uncontrolled and patient was placed on insulin. The patient had diabetes, (Y); The diabetes was uncontrolled on admission (N ). Documentation of diagnoses: One part of combination code is not POA What is POA indicator? POA Indicator for DM, uncontrolled, = “N” NO

31. 2010 UBO/UBU Conference Turning Knowledge Into Action 31 Coding Guidelines for POA Distinguishes between pre-existing conditions and hospital-incurred complications on inpatient claims Conditions which develop during an outpatient encounter, including Emergency Room (ER) encounters, or ambulatory surgery are considered present on admission. Note: For the POA Reporting Guidelines and POA exempt list, see page 100 of the Official Coding Guidelines for ICD-9-CM. http://www.cdc.gov/nchs/data/icd9/icdguide09.pdf http://www.cdc.gov/nchs/data/icd9/icdguide09.pdf

32. 2010 UBO/UBU Conference Turning Knowledge Into Action 32 Pitfall – Loss of Revenue PDX428.31PDX428.31 2°DX427.312°DX427.31 486 *491.21 * DRG 291 DRG 292 Heart Failure & Shock w/MCC w/CC RWP1.4872 RWP0.9164 PPS $12,904 PPS $7,951 FY09

33. 2010 UBO/UBU Conference Turning Knowledge Into Action 33 Pitfall – Loss of Revenue (cont’d) PDX482.41PDX482.41 2°DX599.0 * 2°DX496.0 DRG 178 DRG 179 Respiratory Infection w/CC w/No CC/MCC RWP1.8230 RWP1.0813 PPS $15,818 PPS $9,382 FY09

34. 2010 UBO/UBU Conference Turning Knowledge Into Action 34 Review of Rescue Attempts Clinical Documentation Improvement (CDI) Accurate POA selection Master the Physician Query Process

35. 2010 UBO/UBU Conference Turning Knowledge Into Action 35 Rescue Attempt – CDI Clarify discrepancies found between the Discharge Summary and doctor notes during admission. Coders should utilize ancillary reports as clues to initiate physician queries for clarification. Common DocumentationDocumentation (specificity) Chest PainGERD, non-cardiac pain, type of angina Nursing notes state redness and/or breakdown at pressure points Decubitus Ulcer: site and stage Infiltrates on CXR, Increased MBC, +sputum cultures, fever, dyspnea Pneumonia: possible/probable organism and/or bacterial, viral or aspiration

36. 2010 UBO/UBU Conference Turning Knowledge Into Action Rescue Attempt – POA accuracy Coders must Perform detailed review and analysis of the record Assign POA accurately – Differentiate between Conditions/complications developed during the hospitalization Conditions/complications prior to the admission order (review ER encounter and H/P exam) – If documentation “conflicting, inconsistent or unclear” Query physician Issue must be resolved by the provider Don’t forget ramifications of CC/MCC 36

37. 2010 UBO/UBU Conference Turning Knowledge Into Action Rescue Attempt – Physician Query Clarify clinical relationship between – Clinical findings and – Diagnosis implied by the clinical management (of the patient) Common Query Topics Requiring Clarification – Bacteremia versus Septicemia – Blood loss anemia – Diabetes Mellitus, type and manifestation – Septicemia, Sepsis, and Urosepsis 37

38. 2010 UBO/UBU Conference Turning Knowledge Into Action Summation Documentation is critical to assigning the appropriate diagnoses and procedure codes. – Coding secondary diagnoses is very important! – Don’t forget the “adjectives”! Don’t forget – Official Coding Guidelines (civilian sector) – Military Health System Guidelines for Inpatient Coding Military Health System Guidelines for Inpatient Coding Granularity you need (patient care, research, etc.) The $$$ your MTF deserves! 38

39. 2010 UBO/UBU Conference Turning Knowledge Into Action 39 Questions