Renato L. Estrella, MS, RHIA, Director HIM

1
DRG/Coding Issues and CMS Target Area DRGs
CC Pairs
January 5, 2006

• Renato L. Estrella, MS, RHIA, Director HIM
• Ravi Moses, CCS, Sr. HIM Validator
• Kathy Terry, Ph.D., Sr. Director, Data Analysis
  EvaluationMedicare/Federal Healthcare
  Assessment, IPRO

2
Todays Presentation

• Appropriate for administrators, analytic staff,
  compliance and financial officers, and HIM
  directors and Coding staff.
• Goal is to provide an in-depth discussion of the
  coding issues surrounding the target area of
  complication/co-morbidity (CC) pairs.

3
Todays Agenda

• PEPPER overview
• Diagnosis Related Group (DRG) and Complication
  and Co-morbidity (CC) in brief
• Common denial reasons
• Top error DRGs in detail
• Relevant Hospital Payment Monitoring
• Program projects findings
• Next steps

4
General Training Recap

• PEPPER The Program for Evaluating Payment
  Patterns Electronic Report.
• HPMP and PEPPER an effort to reduce the
  national payment error rate.
• PEPPER
• Presents the pattern of payments made to your
  hospital from CMS compared to the rest of the
  hospitals in your state.
• Focus is only acute care, prospective payment
  system (PPS), short stay inpatient hospitals.

5
General Training Recap

• PEPPER and auditing are part of an Office of
  the Inspector General (OIG) recommended
  compliance program.
• seeking correctly documented and billed Medicare
  charges.
• PEPPER helps hospitals prioritize their on-going
  auditing tasks.
• guiding current and future auditing.
• monitoring (identification and prevention of
  payment errors).

6
General Training Recap

• PEPPER is a report on past administrative claims
  data.
• PEPPER does not identify your hospitals payment
  errors.
• PEPPER indicates which hospitals within the state
  are outliers in terms of the volume of claims
  paid by CMS.
• Concentrates on CMS target areas that are at risk
  for payment errors.

7
PEPPER Target Area

• New target area
• Proportion of discharges for claims with a CC
  relative to all claims in CC pairs.

8
CMS HPMP Target Area

• CMS selected the target areas based on
  historical knowledge, experience and analysis
  of payment errors.
• Demonstration

9
Diagnosis-Related Groups (DRGs) in a Nutshell
DRGs are classifications of medically related
diagnoses where patients have similar lengths of
stay and resource consumption.
10
Diagnosis Related Group

• Currently 559 Medicare DRGs.
• 25 major diagnostic categories.
• Organized into two sections
• - medical (diagnosis codes) and,
• - surgical (operating room procedures).
• Adjusted based on relative weight, arithmetic
• mean length of stay geometric mean
• length of stay.

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Diagnosis Related Group

• Assignment process
• Principal diagnosis and secondary diagnosis and
  procedure codes,
• Sex,
• Age,
• Discharge Status,
• Presence or absence of complications and
• co-morbidities (CCs).

12
Diagnosis Related Group

• When a CC is present as a secondary diagnosis,
  it may affect DRG assignment.
• Complication is a condition that arises during
  hospital stay that prolongs the length of stay
  by at least one day in approximately 75 of the
  cases.
• Co-morbidity is a pre-existing condition and,
• because of its presence with a specific
• diagnosis, causes an increase in length of
• stay by at least one day in approximately
• 75 of the cases.

13
DRG Pair CC Analysis

• CC is required in order to change the DRG to its
  companion DRG that has with CC in its title.
• Example
• DRG 182 - Esophagitis, Gastroenteritis Misc.
• Digestive Disorder Age gt 17 with CC
• Relative Wt. 0.8413.
• DRG 183 - Esophagitis, Gastroenteritis
• Misc. Digestive Disorder Age gt 17
• without CC, Relative Wt. 0.5848.

14
Most Commonly Used CCs

• Anemia due to blood loss, Hematuria
• acute/chronic Hypertensive heart
• Atrial fibrillation/flutter disease w/ CHF
• Congestive heart failure Hyponatremia
• COPD Respiratory failure
• Dehydration Urinary Tract Infection
• Decubitus Ulcer
• Diabetes mellitus
• Hematemesis

15
Most Common Documentation/Coding Issues

• Physician documentation issues
• Quality of physician documentation,
• Communications (query process),
• Physician clinical terminology versus
• ICD-9 (sepsis vs. urosepsis),
• Co-morbidities complications,
• Illegibility,
• Inadequate documentation.

16
Most Common Documentation/Coding Issues

• General documentation issues
• Lack of documentation,
• Absence or presence of documented complications
  and co-morbidities (CCs).
• Impact
• Decreased physician reimbursement,
• Decreased hospital reimbursement,
• Longer length of stay,
• Increased re-admission rates.

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Common Reasons for Denials

• Principal diagnosis is not present at admission.
• Principal diagnosis is not the principal reason
  for hospitalization.
• Complication/co-morbidity/secondary diagnosis
  billed but is not substantiated in the medical
  record.
• Procedures
• billed but not substantiated,
• determined medically unnecessary,
• substantiated in the record, but not billed.

18
Some Top DRGs in Error In Depth Analysis (from
Payment Error Cause Analysis)

DRG 182/183 DRG 296/297 DRG 320/321 DRG
089/090
DRG 174/175 DRG 141/142 DRG 188/189 DRG 079/080
19
Top DRGs by Major Diagnostic Category (MDC)

• MDC 4 Respiratory System
• 079/080 Respiratory Infections Inflammations,
  Agegt17 with or without CC
• 089/090 Simple Pneumonia Pleurisy,
• Agegt17 with or without CC
• MDC 5 Circulatory System
• 141/142 Syncope Collapse with or without CC

20
Top DRGs by MDC

• MDC 6 Digestive System
• 174/175 GI Hemorrhage with or without CC
• 182/183 Esophagitis, Gastroenteritis,
  Miscellaneous Digestive Disorders,
  gt17 with or without CC
• 188/189 Other Digestive System Diagnoses,
  Agegt17 with or without CC

21
Top DRGs by MDC

• MDC 10 Endocrine, Nutritional Metabolic
• 296/297 Nutritional Miscellaneous Metabolic
  Disorders, Age gt17 with or without CC
• MDC 11 Kidney Urinary Tract
• 320/321 Kidney Urinary Tract Infections, Agegt
  17 with or without CC

22
Interpreting PEPPER
23
DRG 182/183

• DRG 182 Esophagitis, gastroenteritis, and
  miscellaneous digestive disorders, agegt17, with
  complication and co-morbidity.
• DRG 183 Esophagitis, gastroenteritis and
  miscellaneous digestive disorders, agegt17,
  without CC.
• Numerator count of discharges to DRG 182 or 183
  with a length of stay less than or equal to one
  day.
• Denominator all DRG discharges to 182 or 183.

24
DRG 182/183

• Common CC dehydration
• Examples
• Good scenario
• Documentation may show that the physician
  thought the patient was dry and he ordered
  fluids, and he states dehydration.
• Less than ideal scenario
• Physician documented signs but did not
  state dehydration. Coder might
  infer that dehydration is a secondary
  diagnosis and, case groups to
  182.

25
DRG 182/183

• Helpful hints
• Cases with signs or symptoms for the principal
  diagnosis must be evaluated to ascertain whether
  or not the documentation substantiates a more
  specific principal diagnosis.
• If there was more than one reason for admission
  and treatment (i.e., gastroenteritis
  dehydration), try to determine from the medical
  documentation if the principal diagnosis is the
  condition that required inpatient treatment.

26
DRG 296/297

• DRG 296 Nutritional and miscellaneous metabolic
  disorders, agegt17, with CC.
• DRG 297 Nutritional and miscellaneous metabolic
  disorders, agegt17 without CC.
• Numerator count of all discharges to DRG 296 or
  297 with length of stay less than or equal to one
  day.
• Denominator all DRG discharges to 296 or 297.
• LOS for DRG 296 is 4.8 and 3.1 for DRG 297.
• LOS less than 3 days for DRG 296/297 may signify
  an improperly assigned case.

27
DRG 296/297

• Issues
• Dehydration vs. acute renal failure.
• Electrolyte imbalance vs. gastrointestinal
  disease and disorder.
• Common CC
• Acute renal failure
• Chronic renal failure
• Diabetes with ketoacidosis.

28
DRG 296/297

• Helpful hints
• When to assign dehydration as principal
  diagnosis
• When a known cancer patient was admitted only for
  management of dehydration.
• When the condition established after study to be
  chiefly responsible for occasioning the admission
  of the patient to the hospital.
• Associated conditions with dehydration include
  acute or chronic renal failure, diabetes with
  ketoacidosis, etc.

29
DRG 296/297

• Codes for signs, or symptoms should not be used
  as the principal diagnosis when a related
  definitive diagnosis has been established.
• Do not code abnormal findings (laboratory,
  x-ray, pathologic and other diagnostic results)
  unless the physician indicates their clinical
  significance.

30
DRG 296/297

• When a patient is admitted with hyperkalemia due
  to non-compliance with dialysis and is treated
  with dialysis, the principal diagnosis should be
  hyperkalemia.
• Determination as to whether or not dehydration
  should be assigned as the principal diagnosis
  depends on the circumstances of the admission and
  the physicians judgment.

31
DRG 320/321

• Issues
• Coding UTI when documentation supports
  septicemia
• Not identifying the condition responsible for
  admission
• Specific site of infection, not documented
• Laboratory findings and physician documentation
• UTI vs. Sepsis
• UTI with LOS gt48 hours may indicate,
  under-coding and might be sepsis.
• Sepsis with LOS lt 48 hours may indicate
  upcoding and might be UTI.

32
DRG 320/321

• Common CC dehydration, acute renal failure,
  sepsis.
• Helpful hint
• If the specific site (cystitis, nephritis) is
  identified the code must be assigned to the
  specific site.
• In cases where documentation indicates urosepsis,
  the physician should be queried on whether the
  urosepsis was intended to mean generalized sepsis
  (septicemia) caused by leakage of urine or toxic
  urine by-products, or the urine contaminated by
  bacteria.

33
DRG 89/90

• Diagnoses that commonly group to DRG 089 are
  pneumococcal pneumonia (streptococcus pneumoniae)
  (481) and pneumonias, not otherwise specified
  (486).
• An abnormal finding on a sputum stain is not
  necessarily indicative of pathogen.
• Never report a diagnosis on the basis of
  abnormal laboratory findings alone.

34
DRG 89/90

• Helpful hints
• Compare discharges for each pneumonia
  DRG to the national and/or state
  norms.
• Note the documentation substantiating
  pneumonia results
  of chest x-ray,
  sputum culture, WBC, and temperature.
• When the physician does not specify
  the causative
  organism or the
  type of pneumonia, code
  486
  unspecified pneumonia, should be
  assigned.

35
DRG 174/175

• Gastrointestinal (GI) hemorrhage may vary widely,
  depending on the site of presentation.
• GI bleeding can vary from occult bleeding to
  acute hemorrhage.
• The same rules apply to the sequencing of codes
  on the digestive system as apply to all other
  systems.
  
• Many GI disorders have a combination code with
  the 5th digit identifying the presence or
  absence of hemorrhage.

36
DRG 174/175

• Now that combination codes are available, the use
  of category 578 (GI hemorrhage) is only to be
  used when a GI bleed is documented but the cause
  or site of bleeding has not been determined.
• Coding DRG 174 is determined by the use of a 5th
  digit code.
• When physician documents that bleeding is not
  due to the GI condition, two codes should be
  assigned, one for GI without hemorrhage and the
  other to identify the type of hemorrhage.

37
DRG 174/175

• Code assignment must be based on physician
  documentation to avoid inappropriately reporting
  incidental findings.
• When a physician lists a diagnosis of guaiac
  positive stool with no indication of the source
  of the bleed or more severe hemorrhage code
  792.1(non specific abnormal findings in other
  body substance stool contents) is assigned.
• Common CC anemia.

38
DRG 141/142

• Syncope
• Syncope may be a symptom of an underlying
  condition.
• When the physician documentation states that the
  syncope was secondary to urinary tract infection,
  or sick sinus syndrome, or atrial fibrillation
  and or electrolyte imbalance, one of these
  conditions may become the principal diagnosis,
  and it may group to a different DRG.
• Example Syncope due to bradycardia.

39
DRG 141/142

• Helpful hints
• When the cause of syncope is not documented,
  query the physician as to whether the cause has
  been established.
• Physician documentation and the coding rules must
  be followed in assigning the principal diagnosis
  of syncope.

40
DRG 188/189

• Common CC dehydration
• A very common co-morbid or complicating condition
  associated with conditions such as burns,
  gastrointestinal disease, peritonitis, ascites,
  renal failure, and urinary tract infections and
  other infections are often accompanied by
  dehydration.

41
DRG 188/189

• Principal diagnosis codes include
• Benign neoplasm of the colon (211.3)
• Hernia (550.xx)
• Foreign body (935.1)
• Includes obstruction, stricture and stenosis due
  to the presence of the foreign body,
• Codes cannot be assigned separately,
• Attention to artificial opening of GI tract
  (V55.x)
• Stomas were created most probably due to
  malignancy of the GI tract.

42
DRG 079/080

• DRG 079 Respiratory infections and
  inflammations, age gt17,with CC.
• Numerator number of discharges coded to DRG 079.
• Denominator number of discharges coded to DRG
  079, 080, 089, 090.
• DRG 79 and 80 are types of pneumonias that
  require longer length of stay and more powerful
  antibiotic treatment than DRG 89 and 90, simple
  pneumonia with or without CC.
• DRG 080 Respiratory infections and
  inflammations,
  agegt17 without CC.
• DRG 089 Simple pneumonia and
  pleurisy, age gt17, without CC.

43
DRG 079/080

• At or above 75th percentile
• Possible coding or billing errors related to
  over-coding,
• Look at principal diagnosis codes 507.x
  (aspiration pneumonia, 482.83 pneumonia due to
  other gram-negative pneumonia, or 482.89
  pneumonia due to another specified bacteria,
• Ensure documentation supports the principal
  diagnosis.
• At or below 10th percentile
• Coding or billing errors related to under-coding.

44
DRG 079/080

• Average national length of stay for DRG 79 is
  8.5.
• Issues
• Claims listed principal diagnosis as specific
  bacterial pneumonia, however documentation only
  supports viral or unspecified pneumonia.
• Longer length of stay.
• Inadequate documentation for pneumonia (history
  and physical exam, no chest x-ray).

45
DRG 079/080

• Common CC COPD
• If there is documentation in the medical record
  to indicate that the patient has COPD, it should
  be coded.
• If the physician mentions the COPD only in the
  history section with no contradictory
  information, the condition should be coded.
• Abnormal findings
• Laboratory, x-ray, pathologic, and
• other diagnostic results.
• (Coding clinic 2002-second quarter article 59)

46
DRG 079/080

• Helpful hints
• Review all pneumonia DRGs and look at the length
  of stay.
• Cases that group to DRG 79 with a LOS lt 8.5 may
  indicate an incorrect code assignment.
• Physician should be responsible for determining
  if the patient has gram-negative pneumonia, even
  in the absence of confirmatory laboratory
  findings.
• If physician does not identify pneumonia
  as aspiration, look for the
  risk factors such as
  bedridden, patients with feeding tubes
  or malnutrition.

47
DRG 079/080

• When the laboratory finding supports a more
  specific diagnosis than the physician has
  documented, query the physician to confirm the
  more specific diagnosis.
• Never assign a diagnosis based on a patients
  signs and symptoms without confirmation by the
  physician.
• Documentation of risk factors, symptoms and
  treatments suggestive of aspiration pneumonia do
  not preclude a
  diagnosis of aspiration pneumonia.
  
• The physician must be queried as to the
  presence or absence of
  aspiration pneumonia.

48
General Guideline

• Principal diagnosis is the key factor in a DRG
  assignment
• Determination depends on the circumstances of
  the admission and the physicians judgment.
• A thorough review of the medical record is
  essential in identifying potential CCs as
  secondary diagnoses.
• Codes for signs and symptoms, and ill defined
  conditions should not be used as the principal
  diagnosis when a related definitive diagnosis
  has been established.

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General Guideline

• When a CC is not present as a secondary
  diagnosis, the case will group DRG without CC.
• In cases where there is disagreement between the
  attending physicians final diagnosis and an
  examination report, the attending determines
  whether or not the medical record documentation
  substantiates the principal diagnosis the
  reason for admission and treatment, and supports
  the complication and/or co-morbidity.

50
HPMP Project Outcome

• HPMP CC Pairs Project 1
• Arkansas DRG 182/183 special project
• Initiated a project to address payment errors on
  DRG 182 and 183.

51
HPMP Project Outcome

• Problems identified
• Underutilization of the observation setting for
  Medicare patients
• Billed principal diagnoses that were not
  supported by chart documentation.
• Billed secondary diagnoses that were not
  supported by chart documentation
• Billed secondary diagnosis of dehydration when
  the diagnosis was not listed by the attending
  physicianin the final diagnostic statement.

52
HPMP Project Outcome

• Factors to consider when analyzing the cause of
  DRG errors
• Is the coding and billing of incomplete records
  causing DRG errors?
• Is inadequate/incomplete physician documentation
  a primary reason for DRG errors?

53
HPMP Project Outcome

• Do you have physicians on your medical staff who
  do not provide a final diagnostic statement?
• Do physicians on your medical staff as a whole,
  or individually, need to be better educated
  regarding Medicare documentation requirements?

54
HPMP Project Outcome

• Are DRG errors occurring because of coding errors
  or because coding guidelines are not being
  followed appropriately?
• Would your hospital benefit from having a
  physician who is on your medical staff serve as a
  physician liaison to address physician
  documentation issues?

55
HPMP Project Outcome

• HPMP CC Pairs Project 2
• Pennsylvania
• Initiated CC pair DRG project (DRG 182/183 and
  296/297).

56
HPMP Project Outcome

• Hospital issues identified
• Hospital continue to code without discharge
  summaries.
• Inconsistencies in the application of query
  processes.
• Coders did not code the most legitimate resource
  intensive DRG.
• Documentation needed on whether dehydration was
  the condition that required admission, or if
  another condition was the cause of dehydration
  and subsequent admission.

57
HPMP Project Outcome

• DRG 182/183 Esophagitis, Gastroenteritis, and
  Miscellaneous Digestive Disorders  
• Found a need to document a specific diagnosis
  (e.g., GERD gastroenteritis, etc.), if known,
  or indicate that the diagnosis cannot be
  further specified.

58
HPMP Project Outcome

• Need for documentation on the
• Significance of abnormal findings (e.g.,
  colonoscopy, EGD, cultures, sigmoidoscopy, etc.)
• Probable cause of symptoms on admission(e.g.,
  abdominal pain, diarrhea, nausea/vomiting, etc.)

59
Where do we go from hereSharing Best Practices

• Conduct regular audits to ensure that the
  accuracy of coding assignment is correct and is
  supported by the documentation in the medical
  record.
• Use PEPPER data to identify areas of potential
  overpayments and underpayments that may require
  auditing and monitoring.

60
Where do we go from hereSharing Best Practices

• Cases with physician documentation problem should
  be referred to a physician for clarification.
• Encourage coders to query the physicians despite
  the pressure to drop the bills fast.
• Review the medical record to
• ensure that the diagnosis billed as principal
  meets the necessary requirements,
• determine if documentation was overlooked that
  could have resulted in a more accurate principal
  diagnosis.

61
Where do we go from hereSharing Best Practices

• Determine if all the secondary diagnoses,
  complications/co-morbidities, and procedures
  billed are supported and coded correctly.
• Implement changes that will eliminate payment
  errors in areas determined to be problematic.
• Abnormal findings documented in the radiological
  reports must be clarified with the physician if
  it is appropriate to add the diagnosis.
  
  Make sure the physician documents the
  diagnosis in the body
  of medical record.

62
Where do we go from hereSharing Best Practices

• Continue to monitor and audit the risk area
  trends to ensure improvement and continued
  compliance.
• Continuous monitoring and auditing allow you to
  target problem areas, and know where to dedicate
  your resources
• Educate all coding staff and physicians on
  correct documentation and coding policies and
  procedures from a clinical and coding
  perspective, not a reimbursement one.

63
Resources

• Coding Clinic 1997, 2nd Quarter, Article 24
• Coding Clinic 1999, 1st Quarter, Article 17
• Coding Clinic 2000, 3rd Quarter, Article 6
• Coding Clinic 2000, 2nd Quarter, Article 11
• Coding Clinic 2003, 1st Quarter, Article 19
• Coding Clinic 2003, 4th Quarter, Article 35
• Coding Clinic 2005, 1st Quarter, Article 1,
  
• Article 32, and Article 88
• Coding Clinic 2005, 3rd Quarter, Article 10
• 2006 Ingenix DRG Expert
• http//www.cdc.gov/nchs/data/icd9/icdguide.pdf

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Contact Information

• Kathy Terry, Ph.D., Sr. Director, Data Analysis
  Evaluation
• Renato L. Estrella, MS, RHIA, Director, HIM
• Ravi Moses, CCS, Sr. HIM ValidatorMedicare/Federa
  l Healthcare Assessment, IPRO
• Email kterry_at_nyqio.sdps.org
  restrella_at_nyqio.sdps.org
  rmoses_at_nyqio.sdps.org
• Web site(s)http//pepperinfo.org/
• http//jeny.ipro.org/forum display.pup?f53