Perhaps the most essential component of physician professionalism is the authority and autonomy to make a clinical diagnosis. As RACs, MACs, QIOs and other entities engage in the DRG Validation process, we have begun to see significant numbers of reversals of clinical diagnoses made by treating physicians. While part of the overall review process, these recent interventions warrant special attention.
Defining the DRG Validation Process
“The purpose of DRG validation is to ensure 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’s description and the information contained in the beneficiary’s medical record. Reviewers shall validate principal diagnosis, secondary diagnoses and procedures affecting or potentially affecting the DRG.(1)”
Coders typically code using encoding software. RAC auditors use similar software that looks back at claims to see if a case has been “maximized” inappropriately, leading to improper payment. Usually, denials can be based on “incorrect coding” in instances in which coders fail to follow established rules. For example, a patient presenting with acute respiratory failure secondary to an antidepressant overdose might be assigned the principal diagnosis of acute respiratory failure (DRG 189). Correct interpretation of coding rules, however, requires a principal diagnosis of poisoning by psychotropic agents, with the respiratory failure being an MCC. A RAC denial due to incorrect coding could result in a substantial financial “takeback” for the admission, as the DRG is reassigned.
This illustration is straightforward and consistent with the intent of CMS, which has provided procedural guidelines for reviewing entities. “The contractor shall base DRG validation upon accepted principles of coding practice, consistent with guidelines established for ICD-9-CM coding, the Uniform Hospital Discharge Data Set data element definitions, and coding clarifications issued by CMS. The contractor shall not change these guidelines or institute new coding requirements that do not conform to established coding rules.(2)”
We recently have seen increasing numbers of denials based on challenges made not to coding practices, but rather to the accuracy of the underlying diagnosis. Such reviews appear to be authorized under the definition of a DRG validation (supra), which states in part that “the purpose of the DRG validation is to ensure that [coding] matches both the attending physician’s description and the information contained in the beneficiary’s medical record.”
Reviewing entities are capitalizing on perceived inconsistencies between the physicians’ descriptions (diagnoses) and other information in the medical record.
The Coding Process
Coders assign and sequence ICD-9-CM codes based on documentation of diagnoses and procedures by treating providers using official coding guidelines published by the National Center for Health Statistics and also found in Coding Clinic, published by American Hospital Association.
CMS directs reviewing entities to ensure that coding guidelines are followed: “the contractor shall determine whether the principal diagnosis listed on the claim is the diagnosis which, after study, is determined to have occasioned the beneficiary’s admission to the hospital. The principal diagnosis (as evidenced by the physician’s entries in the beneficiary’s medical record; see 42 CFR 412.46) must match the principal diagnosis reported on the claim form.(3)”
One QIO recently denied a case coded off a physician’s diagnosis of pathologic fracture. The physician had stated (and the QIO quoted): “her fracture was because of her fall, but she definitely has osteoporosis, which made the fracture more likely to happen and more difficult to fix.” The QIO’s response was: “the physician reviewer stated the patient likely has some degree of osteoporosis; post-menopausal female taking Boniva and calcium supplements. However, the fracture would not have occurred had the patient not fallen over curbing. Thus the fracture is traumatic, not pathologic.”
(1) CMS Manual System, Department of Health & Human Services (DHHS), Pub 100-08 Medicare Program Integrity
Centers for Medicare & Medicaid Services (CMS),Transmittal 264, Date: AUGUST 7, 2008, Change Request 5849, p21
(2) Department of Health &CMS Manual System Human Services (DHHS) Pub. 100-10 Medicare Quality Centers for Medicare & Improvement Organizations Medicaid Services (CMS)
Transmittal 2 Date: July 11, 2003, p22
(3) as above, page 22
Analysis of this case from a coding perspective is interesting. Principal diagnosis is defined by the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital.(4)” The principal diagnosis issued by the treating physician after identifying not only radiographic evidence of severe osteoporosis, but also surgical findings of pathologic changes in the bone, necessitating a more difficult repair, was “pathologic fracture of the humerus.”
The reviewer in this case not only reversed the clinical diagnosis of the treating physician, but also provided his or her personal opinion regarding the diagnosis rather than following the information contained in the Coding Clinic, which governs proper coding. “A pathological fracture is defined as a break in a diseased bone due to weakening of the bone structure by pathologic processes (such as osteoporosis or bone tumors) without any identifiable trauma or following only minor trauma. Only the physician can make the determination that the fracture is out of proportion to the degree of trauma [emphasis added]. X-ray indications of diseased bone may be used by the physician to arrive at a diagnosis of a pathological fracture, but should not be used by coders to make this determination.(5)”
The reviewing physician had stated that “the fracture would not have occurred had the patient not fallen over curbing. Thus the fracture is traumatic, not pathologic.” While the first statement is correct, the conclusion is inconsistent with the Coding Clinic, the treating surgeon’s opinion and common terminology usage in the medical community. The definition of pathologic fractures does not exclude those caused by minor trauma.
Protecting the Diagnosis
As the RACs fully implement their DRG validation processes, there is no question they will adopt strategies currently utilized by QIOs and MACs. HealthDataInsights recently posted its new RAC issues for DRG validation, including, not surprisingly, musculoskeletal fractures. The terminology utilized remains consistent with that of the QIO example [supra]: “DRG validation [for musculoskeletal fractures] requires that diagnostic and procedural information… matches both the attending physician description and the information contained in the beneficiary’s medical record.(6)”
Many challenges to correctly coded medical records can be reversed through a timely, aggressive appeal process. However, this should not be the sole strategy utilized by providers. By informing physicians of the attempted assault on the core of their professionalism, their ability to make clinical diagnoses, we can improve markedly the quality of clinical documentation on the front end – pre-empting potentially antagonistic interpretations by reviewing entities.
Ambiguity in physician documentation remains an open portal to challenges by RACs, MACs, QIOs and others. Accurate, consistent and compliant documentation is a powerful catalyst for appropriate payment under the DRG system and now is essential to avoid RAC takebacks.
According to CMS, “the purpose of DRG validation is to ensure that diagnostic and procedural information and the discharge status of the patient, as coded and reported by the hospital on its claim, matches both the attending physician’s description and the information contained in the patient’s medical record.(7)”
It is apparent that a physician’s diagnosis alone no longer is sufficient to deter alternative interpretations by financially incentivized reviewers. As we move forward, we need to ensure that the treating physician documents not only appropriate diagnoses, but also clinical, laboratory and radiographic findings supporting such diagnoses.
(4) ICD-9-CM Official Guidelines for Coding and Reporting Effective October 1, 2009 Page 91 of 112
(5) Coding Clinic; Pathological Fracture, Code 733.1, Coding Clinic 4th Qtr. 1993, pp. 25-26
(7) Department of Health &CMS Manual System Human Services (DHHS) Pub. 100-10 Medicare Quality Centers for Medicare & Improvement Organizations Medicaid Services (CMS), Transmittal 2 Date: July 11, 2003.
About the Author
Paul Weygandt, MD, JD, MPH, MBA, CPE
Paul Weygandt is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Dr. Weygandt is vice president of physician services for J.A. Thomas & Associates and is a partner in the firm.
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