Risk areas should be addressed with coding audits, coding education, clinical documentation improvement programs, utilization review and case management guidelines, medical necessity guidelines and physician education.
Inpatient
• Respiratory Dxes w/Ventilator (old DRG 76) (incorrect code)
– MSDRG 166 – Other Respiratory System OR Procedures w/MCC
– MSDRG 167 – Other Respiratory System OR Procedures w/CC
– MSDRG 168 – Other Respiratory System OR Procedures w/o CC/MCC
• Respiratory Infections & Inflammations, Age > 17 w/CC (old DRG 79) ¹(incorrect code)
– MSDRG 177 Respiratory Infections & Inflammations w/MCC
– MSDRG 178 Respiratory Infections & Inflammations w/CC
– MSDRG 179 Respiratory Infections & Inflammations w/o CC/MCC
• Respiratory System diagnosis with Ventilator Support (old DRG 565/566) ¹(incorrect code)
– MSDRG 207 Respiratory System diagnosis w ventilator support 96+ hours
– MSDRG 208 Respiratory system diagnosis w ventilator support <96 hours
• Other Circulatory System OR Procedures (old DRG 120) ¹ (incorrect code)
– MSDRG 264 Other circulatory system OR Procedures
• MS DRGs 286/287 – Circulatory Disorders except AMI w/Caridac Cath w MCC/woMCC2
– Treated in wrong setting (medically unnecessary)
• MS DRGs 291/292/293 Heart Failure/Shock w MCC/w CC/wo CC/MCC2
– Treated in wrong setting (medically unnecessary)
– Coding errors
• MS DRGs 308/309/310 Cardiac arrhythmia & Conduction disorders wMCC/w CC/wo CC/MCC (incorrect code)
• Chest pain (Old DRG 143) ¹(medical necessity)
– MSDRG 313 Chest Pain
• Excisional Debridement (incorrect code)¹,²
– Wound Debridement & Skin graft except hand, for musculoskeletal and connective tissue disorders (old DRG 217)
- MSDRG 463 Wound debridement & skin graft except hand for musculoskeletal connective tissue disease w MCC
- MSDRG 464 Wound debridement & skin graft except hand for musculoskeletal connective tissue disease w CC
- Wound debridement & skin graft except hand for musculoskeletal connective tissue disease w/o CC/MCC
– Medical Back Problems (old DRG 243) (medical necessity)
- MSDRG 551 Medical Back Problems w/MCC
- MSDRG 552 Medical Back Problems w/oMCC
– Skin Graft and/or Debridement for Skin Ulcer or Cellulitis w/CC(old DRG 263)¹,² (correct coding)
- MSDRG 573 Skin graft &/or debridement for skin ulcer or cellulitis w/MCC
- MSDRG 574 Skin graft &/or debridement for skin ulcer or cellulitis w/CC
- MSDRG 575 Skin graft &/or debridement for skin ulcer or cellulitis w/o CC/MCC
• MS DRGs 640/641 Nutritional & Metabolic disorders wMCC/woMCC (correct coding)
• Septicemia (old DRG 576)¹,² (coding)
– MSDRG 870 Septicemia w MV 96+ hours
– MSDRG 871 Septicemia w/o MV 96+ hours w/MCC
– MSDRG 872 Septicemia w/o MV 96+ hours w/o MCC
• Extensive OR Procedure unrelated to principal diagnosis (old DRG 468) ¹(coding)
– MSDRG 981Extensive OR procedure unrelated to principal diagnosis w/MCC
– MSDRG 982 Extensive OR procedure unrelated to principal diagnosis w/CC
– MSDRG 983 Extensive OR procedure unrelated to principal diagnosis w/oCC/MCC
– MSDRG 853 Infectious & parasitic diseases w OR procedure w/MCC
– MSDRG 854 Infectious & parasitic diseases w OR procedure w/CC
– MSDRG 855 Infectious & parasitic diseases w OR procedure woCC/MCC
• Other Cases with high MS-DRG weight with low charges or LOS (coding)
• MCC/CC triplet rate (high % of claims assigned to MS-DRGs with MCC or CC in comparison with other facilities) (coding)
Discharge Status Codes²
Patients went to sub acute care and billed with “01”
Outpatient²
- Neulasta (medically unnecessary)
- Speech Language Pathology (medically unnecessary)
- Therapy units billed(medically unnecessary)
- Infusion Services (medically unnecessary)
– Multiple Colonoscopies (45355, 45378, 45380, 45383, 45384, 45385) (medically unnecessary)
– Multiple procedures on the same day (medically unnecessary)
- E.g. CPT code 47562 (Cholecystectomy) 3 units billed
• Outpatient charges without Medical Necessity diagnoses (LCD or NCD)
• Inpatient Medical Necessity Targets
– Short Stays with weak principal diagnoses
- Abdominal Pain
- Asthma
- Dehydration
- Diabetes
– 1 day stays
– 3-day stays with discharge status of discharge to SNF
– Readmissions within 72 hours of discharge
– IRF following joint replacement surgery
– Cardiac defibrillator implant in wrong setting
– 7 day readmit to same or other acute facility (early discharge?)
There are other targets to consider as well. The Office of Inspector General (OIG) and other CMS agencies have a list of targeted DRGs which the RAC may use as a basis for a complex review. These targets are:
|
Old DRG |
Description |
MS-DRG |
|
014 |
Intracranial Hemorrhage & Stroke with Infarction |
064, 065, 066 |
|
015 |
Nonspecific Cerebrovascular and precerebral occlusion without infarction |
067, 068 |
|
524 |
Transient Ischemia |
069 |
|
|
|
|
|
079 |
Respiratory infections & inflammations >17 w/CC |
177, 178 |
|
080 |
Respiratory infections & inflammations w/oCC |
179 |
|
089 |
Simple Pneumonia & Pleurisy >17 w/CC |
193 |
|
|
|
|
|
087 |
Pulmonary edema & Respiratory failure |
189 |
|
088 |
COPD |
190, 191, 192 |
|
127 |
Heart Failure & Shock |
291, 292, 293 |
|
|
|
|
|
088 |
COPD |
190, 191, 192 |
|
096 |
Bronchitis & Asthma >17 w/CC |
202 |
|
|
|
|
|
089 |
Simple Pneumonia & Pleurisy >17 w/CC |
193 |
|
096 |
Bronchitis & Asthma >17 w/CC |
202 |
|
|
|
|
|
121 |
Circulatory Disorders w/AMI & Major Complications, Discharged Alive |
280 |
|
124 |
Circulatory Disorders except AMI w/Cardiac cath and complex diagnosis |
286 |
|
|
|
|
|
122 |
Circulatory Disorders w/AMI wo major complications, discharged alive |
281, 282 |
|
125 |
Circulatory Disorders except AMI w/Cardiac cath wo complex diagnosis |
287 |
|
|
|
|
|
127 |
Heart Failure & Shock |
291, 292, 293 |
|
140 |
Angina Pectoris |
311 |
|
|
|
|
|
130 |
Peripheral Vascular Disorders w/CC |
299, 300 |
|
128 |
Deep Vein Thrombophlebitis |
294, 295 |
|
|
|
|
|
132 |
Atherosclerosis w/CC |
302 |
|
140 |
Angina Pectoris |
311 |
|
|
|
|
|
138 |
Cardiac arrhythmia & conduction disorders w/CC |
308, 309 |
|
140 |
Angina Pectoris |
311 |
|
|
|
|
|
140 |
Angina Pectoris |
311 |
|
143 |
Chest Pain |
313 |
|
|
|
|
|
174 |
GI Hemorrhage w/CC |
377, 378 |
|
182 |
Esophagitis, Gastroenteritis, & Misc, Digestive Disorders >17 w/CC |
391 |
|
|
|
|
|
188 |
Other Digestive System Diagnosis >17w/CC |
393, 394 |
|
180 |
GI Obstruction w/CC |
389 |
|
|
|
|
|
239 |
Pathological Fracture & Musculoskeletal & Connective Tissue Malignancy |
542 |
|
243 |
Medical Back Problems |
551, 552 |
|
|
|
|
|
296 |
Nutritional & Misc. Metabolic Disorders >17 w/CC |
640 |
|
182 |
Esophagitis, Gastroenteritis & Misc. digestive disorders >17 w/CC |
391 |
|
|
|
|
|
316 |
Renal failure |
682,683 |
|
331 |
Other Kidney & Urinary tract diagnoses >17 w/CC |
698, 699 |
|
|
|
|
|
320 |
Kidney & UTI >17 w/CC |
689 |
|
296 |
Nutritional & Misc. metabolic disorders >17 w/CC |
640 |
|
|
|
|
|
416 |
Septicemia >17 |
871, 872 |
|
320 |
Kidney & UTI >17 w/CC |
689 |
|
|
|
|
|
430 |
Psychoses |
885 |
|
425 |
Acute Adjustment Reactions & disturbances of psychosocial dysfunction |
880 |
|
|
|
|
|
565, 566 |
Respiratory system diagnosis with ventilator support |
207, 208 |
|
121 |
Circulatory disorders w/AMI & major complications, discharged alive |
280, 281, 282 |
|
|
|
|
|
565, 566 |
Respiratory system diagnosis with ventilator support |
207, 208 |
|
127 |
Heart Failure & Shock |
291, 292, 293 |
|
|
|
|
In the coming months, I will present in depth discussions of these targets and the pertinent coding and medical necessity issues involved.
____________________
¹ VHA Presentation 2008
² The Medicare Recovery Audit Contractor (RAC)Program: Update to the Evaluation of the 3-year Demonstration June 2008
###
About the Author
Cheryl Servais has more than 25 years of experience in Health Information Management. In her position at Precyse Solutions, Ms. Servais’ responsibilities include planning, designing, implementing and maintaining corporate-wide compliance programs, policies and procedures, and updating them to accommodate changes in federal and other regulations. In addition, she oversees training and development programs related to ethics, compliance and patient privacy; develops and chairs compliance and privacy advisory committees at the Executive and Board levels; and takes an active role in professional organizations.
Cheryl E. Servais, MPH, RHIA, is Vice President, Compliance and Privacy Officer for Precyse Solutions
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