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RAC Targets: The Best Offense Is a Good Defense Mario A. Perez, III, RHIA, CCS-P, CDIP Director, Clinical Consulting JA Thomas, Atlanta, GA Slides created by: Vickie L. Balistreri, BA, RHIA, CCDS, CCS-P, CPC-H, AHIMA-Approved ICD-10 -CM/PCS Trainer
Agenda • • • Respiratory failure Functional quadriplegia One-day stays: Medical necessity Osteoporotic fracture vs. traumatic fracture Sepsis: Multi issues DRGs 981, 982, 983: Principal diagnosis unrelated to principal procedure
Best Defense Against RAC Is a Good Offense • CDI programs not only assist in obtaining the proper documentation but in protecting the integrity of our records • Since RACs use data mining to determine their best or easiest targets, it makes sense to look at our records and strive to make our records less vulnerable • A robust clinical documentation program will not only obtain documentation that will improve the CMI but will also improve documentation of severity of illness—not just one MCC but multiple MCCs, not just one CC but multiple CCs • This will also assist with accurately showing the expected morbidity or risk of mortality
RAC Target: DRGs Designated as CC or MCC With Only One Secondary Diagnosis • RACs identified improper payments due to the coding of DRGs with complications or comorbidities (CC) or major complications or comorbidities (MCC) with only one MCC or CC • Examples of these include: – MS-DRG 329, major small and large bowel with MCC – MS-DRG 330, major small and large bowel with CC – MS-DRG 331, major small and large bowel w/o cc/MCC – Documentation does not support code assigned – For example: 285. 1 as single CC
Common RAC Targets
Respiratory Failure as Principal Diagnosis • Reasons for RAC denials: When coding does not follow chapter-specific coding guidelines that provide sequencing direction or take precedence, meaning respiratory failure may not be assigned as the principal diagnosis – Poisonings – HIV – Sepsis – Obstetrics – And newborn
Acute Respiratory Failure Noted in ER Documentation • Be cautious; although we can use documentation from the ER record, RAC auditors are looking at the rest of the record to see if the acute respiratory failure is on the admitting order and is carried over into the H&P. They are trying to state that the acute respiratory failure resolved prior to admission. • Many times acute respiratory failure resolves very quickly; however, it is the reason or what occasioned the admission to the hospital. • Acute respiratory failure indicators: – Respirations > 28 – Air hunger – Use of accessory muscles of – – – respiration Inability to speak in full sentences Cyanosis Pulse ox < 90% RA or < 95% on O 2 p. H < 7. 35 or > 7. 45 p. O 2 < 60 mm Hg (or 10 mm below COPD patient's baseline) p. CO 2 > 50 mm Hg (or 10 mm above COPD patient's baseline)
Chapter-Specific Coding Guidelines: p. 42, ICD-9 -CM Official Guidelines for Coding and Reporting (effective 10/1/09) Chapter 8: Diseases of Respiratory System • If both the respiratory failure and the other acute condition are equally responsible for occasioning the admission to the hospital, and there are no chapter-specific sequencing rules, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II, C. ) may be applied in these situations. • If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.
Chapter-Specific Coding Guidelines: p. 42, ICD-9 -CM Official Guidelines for Coding and Reporting (effective 10/1/09) Chapter 8: Diseases of Respiratory System • 3) Sequencing of acute respiratory failure and another acute condition When a patient is admitted with respiratory failure and another acute condition (e. g. , myocardial infarction, cerebrovascular accident, aspiration pneumonia), the principal diagnosis will not be the same in every situation. This applies whether the other acute condition is a respiratory or nonrespiratory condition. • Selection of the principal diagnosis will be dependent on the circumstances of admission.
RAC Target: Wrong Principal Diagnosis • RACs also cited principal diagnosis as a leading area of concern. • RACs found that the 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 that sepsis (code 038. 0– 038. 9) was the principal diagnosis.
Unspecified Heart Failure as PDX 428. 0 -CHF unspecified – What’s the issue? Records have been targeted for review for PDX 428. 0 (data mining) congestive heart failure. – Without documentation of the type of congestive heart failure, systolic or diastolic, even if the CHF is acute there is no other code other than 428. 0 that can be assigned. – Although CHF (428. 0) can be assigned as a principal diagnosis, this code has been targeted for increased scrutiny to see if the CHF truly occasioned the admission or if the PDX of CHF has been inaccurately assigned.
RAC Target: Conflicting Documentation • Conditions documented in the record different ways such as: – Respiratory distress vs. respiratory failure – Renal insufficiency vs. acute renal failure vs. prerenal azotemia – Urosepsis vs. sepsis • Recommendation: – Have attending physician restate what truly occasioned the admission, such as the acute respiratory failure or acute renal failure, in the body of the record and indicate how it drove admission and/or is now resolving
RAC Target: Pathologic Fractures DRGs 542, 543, 544
Pathologic Fractures • What’s the issue? Does the documentation support a pathologic fracture? – Main problem is documentation of “compression fracture. ” • Compression fractures can be either due to trauma or due to pathologic fracture or “weakness in bone” so compression fractures could be miscoded as pathologic fractures when there is no documentation to support this. • Further, if the patient has even minor fall (from bed to carpet) some auditors are changing the PDX to traumatic fracture vs. osteoporotic fracture.
Pathologic Fractures A pathologic fracture occurs when a bone breaks in an area that is weakened by another disease process. The bone is broken not by trauma alone, but is so weakened by disease as to break with abnormal ease. Pathologic fractures are characteristic of metastatic lung and breast cancer and myeloma. Causes of weakened bone include: • Tumors • Infection • Osteoporosis • Certain inherited bone disorders • Dozens of other diseases and conditions that can cause a pathologic fracture
Other Respiratory System Operating Room Proc (MS-DRGs 166– 168)
Other Respiratory System Operating Room Proc (MS-DRGs 166– 168) The issues: • Was the purpose of the procedure a transbronchial lung biopsy, or was it a closed endoscopic biopsy of the bronchus? • Was the correct site of the biopsy correctly coded? For example: Closed endoscopic biopsies of the lung fall into MS-DRGs 166– 168, but closed endoscopic biopsies of the bronchus do not. • Did the patient have an excisional debridement? (Lung diagnoses with excisional debridements group into MSDRGs 166– 168, not into the debridement MS-DRGs. )
Respiratory System Diagnosis With Vent Support 96+ Hours (MS-DRG 207)
Respiratory System Diagnosis With Ventilator Support 96+ hours (MS-DRG 207) The issues: • Are the hours on ventilator support calculated correctly? • Do you have sufficient documentation to support the 96+ (continuous) hours on ventilator support? • Are coders following AHA Coding Clinic advice? Refer to Fourth Quarter 1991.
Sepsis Without Mechanical Vent With Or Without MCC (DRGs 871– 872)
Sepsis Without Mech Vent 96+ Hours (MS-DRGs 871– 872) The issues: • Does documentation within the medical record support the diagnosis of sepsis present on admission, or did it develop after admission? • Is sepsis due to an infected catheter, line, device, etc. ? • Has the physician been queried in reference to his or her clinical diagnosis of urosepsis?
Sepsis Due to Indwelling Catheter, Vascular Device, Etc. • If sepsis is “due to” a vascular device, indwelling catheter, infusion catheter, etc. , it should go to a DRG other than 871– 872 depending on the type of device (often lower weighted DRG)
Excisional Debridement: The Issue • In order to code excisional debridement, documentation must meet the requirements outlined in the 1991 Third Quarter AHA Coding Clinic. If the documentation does not meet these requirements, the procedure should be coded to the nonoperative ICD-9 -CM code 86. 28, nonexcisional debridement.
Excisional Debridement • Excisional debridement requires very specific medical record documentation in order to assign a code for the procedure. Obtaining accurate and complete documentation to support code assignment frequently involves educating providers on components needed in the documentation to support the code. Include: – Cutting instrument used – Size – Depth – Removal of devitalized tissue – Definite cutting away of tissue (not minor removal of loose fragments) – “Excisional debridement”
Excisional Debridement: Does Code Describe Correct Depth? Excisional debridement Coding Clinic, First Quarter 2008, p. 3 Effective with discharges: March 21, 2008 Question: The physician debrided a coccyx wound with sharp excision down to the fascia and bone. How should the debridement down to the bone be coded? Answer: Assign code 77. 69, Local excision of lesion or tissue of bone, other, for the sharp debridement of the fascia down to the bone. When multiple layers of the same site are debrided, assign only a code for the deepest layer of debridement. Refer to Coding Clinic, First Quarter 1999, pages 8 to 9, for additional information regarding extensive wound debridement.
RAC Target: Functional Quadriplegia • Functional quadriplegia is not a true paresis. It is the inability to move due to another condition (e. g. , dementia, severe contractures, arthritis, etc. ). • The patient is immobile because of a severe physical disability or frailty. There is usually some underlying cause, which most often will involve severe dementia. The individual does not have the mental ability to ambulate and functionally is the same as a paralyzed person.
Functional Quadriplegia • RAC target: Does patient fit the definition? Is he or she quadriplegic due to another source? Functional quadriplegia cannot be used for neurological sources. • Is the patient hemiplegic or quadriplegic? Hemiplegia is partial paralysis, which would not be appropriate.
Excludes Notes for Functional Quadriplegia Excludes notes • Instructional notes in the Tabular indicate that neurologic quadriplegia (344. 00– 344. 09), hysterical paralysis (300. 11), and immobility syndrome are excluded from code 780. 72 Coding Clinic, Fourth Quarter 2008, p. 143 New codes effective with discharges: October 1, 2008 Other coding advice or code assignments contained in this issue effective with discharges: October 24, 2008
Short-Stay MS-DRGs Under Review MS-DRGs Description Coding/documentation issue 64, 65, 66 CVA Incorrect PDX, infarction/hemorrhage ruled in? 291, 292, 293 HF & shock Correct PDX: 428. 0 in first position does not show exacerbation or acute, need documentation of type and severity acute, acute on chronic 313 Chest pain Incorrect PDX, underlying cause determined? 391, 392 Esophagitis, gastroenteritis, misc GI disorders Incorrect PDX, underlying cause determined? 551, 552 Medical back problems Incorrect PDX 640, 641 Nutrition & metabolic disorders Incorrect PDX, underlying cause determined? 689, 690 Kidney & urinary tract disorders Incorrect PDX
DRG 690: UTI Without MCC Huge target of quite a few denial agencies for main reason: Does it meet criteria for inpatient stay?
DRGs 981, 982, 983: Extensive OR Procedure Unrelated to Principal Diagnosis w/o CC/MCC (1. 7404) • If the principal diagnosis is one of the diagnoses that occasioned the admission, then the principal diagnosis and the principal procedure should be in the “same family” or match. • For example, if a patient comes in with no blood flow to the lower extremities, shortness of breath, and UTI, even if the fem popliteal surgery is performed later in the stay, your PDX would be the vascular insufficiency or PVD with the vascular surgery. Many times the patient will need to be stabilized before surgery.
DRGs 981, 982, 983: Principal Diagnosis Unrelated to Principal Procedure • The purpose of these DRGs are when the patient is admitted for a particular condition and then later another problem not POA is identified and treated surgically. Should be more rare or unusual. – For example, patient comes in for atherosclerosis of femoral artery—fem pop is done and later patient gets up and falls and has to have a craniotomy to reduce cerebral edema and intracranial bleed.
RECOVERY AUDIT CONTRACTORS 4 th Quarter Results
Recovery Audit National Program: Fiscal Year 2012
Top Issue Per Recovery Auditor
Recovery Audit Regions http: //www. cms. gov/Recovery-Auditprogram/Downloads/FY 2010 Report. Congress. pdf
Summary • A robust clinical documentation and improvement program helps to protect your records against RAC • Correct documentation not only helps with RAC but will be better reflective of the suspected morbidity and mortality of the patient, which is becoming more and more important in today’s quality and Health. Grades measuring systems
Questions? In order to receive your continuing education certificate for this program, you must complete the online evaluation which can be found in the continuing education section at the front of the workbook.