Briefing: Inpatient Institutional (Hospital) Coding Date: 21 March 2007 Time: 0800 - 0850

1. Briefing: Inpatient Institutional (Hospital) Coding Date: 21 March 2007 Time: 0800 - 0850

2. Objectives • Understand the definitions for code selection and sequencing • Discuss documentation needs, current and future • Identify deficiencies in hospital coding • Identify coding opportunities to excel • Discuss Services biostatistical processing of Standard Inpatient Data Records (SIDRs)

3. Definitions – Diagnoses Mission of the National Committee on Vital and Health Statistics (NCVHS) to standardize health data sets http://www.ncvhs.hhs.gov/ncvhsr1.htm(’96 Report) • Principal Diagnosis • Condition/diagnosis established, after study, to be responsible for admission of patient to the hospital • May or may not match the admitting diagnosis • Use entire record to substantiate the principal diagnosis • Secondary Diagnoses • Complication– Arises during hospital stay, usually prolongs length of stay, and requires additional resources to manage • Co-morbidity– A pre-existing condition causing an increase in the length of stay, in most cases

4. Principal Diagnosis • Scenario 1: Patient admitted with fever, severe RLQ pain, and elevated white cell count. Patient was taken to surgery and ruptured appendix was removed • Fever • RLQ Pain • Elevated white cell count • Ruptured appendix • Scenario 2: Patient was admitted for severe fatigue. The discharge diagnosis was noted to be fatigue (780.79) due to hypothyroidism (244.9) or prolonged situational depression (309.1) A. Fatigue B. Hypothyroidism C. Prolonged Situational Depression

5. Definitions – Procedures • Procedures (inpatient) – All significant procedures, and dates performed, are to be reported. A significant procedure is one that is: • Surgical in nature, or • Carries a procedural risk, or • Carries an anesthetic risk, or • Requires specialized training • Surgery includes incision, excision, amputation, introduction, endoscopy, repair, destruction, suture, and manipulation • Principal Procedure Uniform Hospital Discharge Data Set (UHDDS) Definition of significant procedure: “Principal Procedure (inpatient) – As recommended by the UHDDS, the principal procedure is one that was performed for definitive treatment, rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication. If there appear to be two procedures that are principal, then the one most related to the principal diagnosis should be selected as the principal procedure...”

6. Principal Procedure • DG01 66101 Primary uterine inertia, delivered, with or without mention of antepartum condition • DG02 65811 Premature rupture of membranes, delivered, with or without mention of antepartum condition • DG03 2189 Leiomyoma of uterus, unspecified • DG04 V270 Mother with single liveborn • OP01 741 D01 Low cervical cesarean section • OP02 6829 D01 Other excision or destruction of lesion of uterus

7. Principal Procedure 575.0 Acute cholecystitis 584.9 Acute renal failure, unspecified 518.81 Acute respiratory failure 482.83 Pneumonia due to other gram-negative bacteria 038.42 Septicemia due to Escherichia coli (E-coli) 995.91 Sepsis 599.0 Urinary tract infection 31.29 Other permanent tracheostomy 51.01 Percutaneous aspiration of gallbladder 96.04 Insertion of endotracheal tube 96.72 Continuous mechanical ventilation for 96 consecutive hours or more ….. etc.

8. Documentation, Why Improve? • Accurately capture inpatient services rendered • Hospital coding (SIDR) • Rounds encounters (SADR) • Collect accurate and complete clinical documentation at the point of care • Improve patient care • Reflect true case complexity and severity • Optimize reimbursement (DRG) • Increase Relative Weighted Product (RWP) • Increase case mix • Decrease reimbursement denial rates • Enhance clinical communications • Support epidemiology and research data

9. Documentation – How to Improve • Identify the team • POCs from HIM, Case Management, and Nursing • Physician champion • Define responsibilities • Develop a plan for audits • Identify target DRGs • Identify problem areas – documentation, miscoding, etc. • Monitor results • Provide reports (report cards) • Communicate results (From article by Rose Dunn. Adapted from the book Coder Productivity / www.hcmarketplace.com/prod-4059.html)

10. Deficiencies in Hospital Coding • Diagnoses • Not coded • Complications and co-morbidities • Allergies, tobacco use/abuse, E-codes (injuries) • No documentation to support code selection • Pregnancy and delivery complications • Other diagnoses • ICD-9-CM code specificity and sequencing • Procedures • Missed procedures • Code specificity – incorrect at 4th level

11. What to Look for When Auditing • All relevant documents are in the record • Principal diagnosis is properly identified • Additional diagnoses (complications, co-morbidities) are coded • Principal procedure is properly identified • Additional procedures are coded • All codes are identified and sequenced IAW UHDDS, DoD, and CMS Official Coding Guidelines • All codes assigned to the highest level of specificity

12. Audits and Hospital Coding • Did you validate the coding error? • Legitimate • Who decided on the plan of action? • Were the record(s) corrected? • Did it require a follow-up/focused internal audit? • Are activities documented? • Questionable • Did you question the results of the audit? • Can the auditor give you supporting reference(s) for code selection? • Were Service POCs advised? • Is this process covered in your Compliance Plan?

13. DRG Targeted Reviews • Overcoding • DRG 468, extensive OR procedure unrelated to principal diagnosis • DRG 079, respiratory infections & inflammations • DRG 416, septicemia • Etc. • Undercoding • DRG 089, simple pneumonia • DRG 002, craniotomy • DRG 443, other OR procedures/injuries without CC • DRG 143, chest pain • Etc, • Medical Necessity – One-day stays, excluding transfers, for specific DRGs (127, 143, 182/183, 296/297) • Readmissions within 7 days

14. DRG 468 • DG01 873.1 OPEN WOUND OF SCALP, COMPLICATED • DG02 805.07 CLOSED FRACTURE OF SEVENTH CERVICAL VERTEBRA WITHOUT MENTION OF SPINAL CORD INJURY • DG03 805.21 CLOSED FRACTURE OF DORSAL [THORACIC] VERTEBRA WITHOUT MENTION OF SPINAL CORD INJURY • DG04 870.8 OTHER SPECIFIED OPEN WOUNDS OF OCULAR ADNEXA • DG05 820.20 CLOSED FRACTURE OF UNSPECIFIED TROCHANTERIC SECTION OF FEMUR • DG06 886.0 TRAUMATIC AMPUTATION OF OTHER FINGER(S) (COMPLETE) (PARTIAL) • DG07 873.50 OPEN WOUND OF FACE, UNSPECIFIED SITE, COMPLICATED • DG08 E812 OTHER MOTOR VEHICLE TRAFFIC ACCIDENT INVOLVING COLLISION WITH MOTOR VEHICLE, PASSENGER IN MOTOR VEHICLE OTHER THAN MOTORCYCLE • DG09 810.00 CLOSED FRACTURE OF CLAVICLE, UNSPECIFIED PART • OP01 02.94 INSERTION OR REPLACEMENT OF SKULL TONGS OR HALO TRACTION DEVICE • OP02 86.59 CLOSURE OF SKIN AND SUBCUTANEOUS TISSUE OF OTHER SITES • OP03 93.41 SPINAL TRACTION USING SKULL DEVICE

15. Optimize, Not Maximize Scenario1a: Optimized (Correct) Coding Dx 552.21 Incisional hernia with obstruction DRG: 189 (Other Digestive System Dx, Age >17 w/o CC) RWt: .60640 Scenario 1b: Maximized (Unbundled/incorrect) Coding Dx 552.21 Incisional hernia with obstruction Dx 560.9 Intestinal obstruction, NOS DRG: 188 (Other Digestive System Dx, Age >17 w/CC) RWt: 1.1290 From ADVANCE article, September 11, 2006

16. OIG Examines • http://oig.hhs.gov/publications/workplan.html • “Medical Appropriateness and Coding of Diagnosis Related Group Services - We will analyze inpatient hospital claims to identify providers who exhibit high or unusual patterns for selected DRGs. We will then determine the medical necessity, the appropriate level of coding, and reimbursement for a sample of services billed by these providers…” (from the OIG Workplan document)

17. OIG Examined in 2006 • Coronary Artery Stents – Peripheral artery and other stents, drug-eluting vs standard • Tip: Coders, learn brand names of stents • Tip: Physicians, document % occlusion • Catheter procedures • Tip: Designate coder to perform difficult coding • Problematic DRGs and other data elements • Tip: Review past problematic DRGs (127, 143, 182, 183, 296, 297, 014, 079, 089, 243, 416) • Tip: Review correctness of nursing discharge type • Tip: Perform focused audits (medical necessity of observation admissions, one-day stays, etc.)

18. SIDR Editing Process in CHCS • Records go through CHCS and Service-specific edits • “D” status records (CHCS status: completed) • Demographics • Diagnoses and procedures • DRG and other related fields • Records fail edits • Valid error – Fix it! • Invalid error • Discuss with Service POC • Discuss with CHCS/SAIC representative at MTF • MHS Help Desk 1-800-600-9332

19. Common Edit Failures – Army • #1175, 1215, etc. – Invalid Diagnosis #X DoD Extender Code • #00163 – Ben Cat inconsistent with Duty Station Zip Code • #01130 – External Cause of Injury Inconsistent with Dx • #00185 – AD A, N, AF, MC BEN CAT inconsistent w/Location of Unit (invalid code used) • #02635 – Invalid Primary Provider Specialty • #00990, 01005 – Invalid MTF of Initial Adm or TRF/moved from • #00305 – Pay Grade coded for other than active duty, retired, or former AD TAA BEN CAT If EXTERNAL CAUSE OF INJURY is coded 000-289 or 300-999, then at least one diagnosis in DG #1-DG #X must be coded 800-904,910-999, or E80-E99 in the first three positions or V713-V716 in the first four positions or 69271 in the first five positions. Effective: Oct 02 – Sep 04

20. Common Edit Failures – Air Force • #00180C – AD AF PATCAT with invalid MOS (Military Occupation Code) • #00370 – Blank MOS code inconsistent with PATCAT • #0350B – Blank FLYING STATUS inconsistent with PATCAT • #0335B – Blank LENGTH of SVC inconsistent w/ PATCAT • 02635 – Invalid PRIMARY PROVIDER SPECIALTY • #00185 – AD Army, Navy, Marines, or Air Force PATCAT inconsistent with UNIT LOCATION • #00200 – AD Army, Navy, Marines, or Air Force PATCAT inconsistent with ETHNIC BACKGROUND

21. Common Edit Failures – Navy • #00620 – LB Source of Adm inconsistent with Age at Adm • #00662 – Live birth Source of Admission inconsistent with Admission Date and Date of Birth • #00100 – Invalid Age at Admission (age over 99Y) • #00130 – Invalid Age at Disposition (age over 99Y) • #01645 – Liveborn, perinatal, or childhood Diagnostic Code inconsistent with BEN CAT

22. SIDR Transmittals, Metrics, and Reports • SIDR Transmittals (to Service repositories) • Army (5th calendar & 20th calendar day/mo ) • Navy (10th calendar day/mo ) • Air Force (5th working day/mo) • Monitor transmittals • Timely • Complete • Review metrics and reports • BDQAS: https://bdqas.brooks.af.mil • PASBA: https://pasba3.amedd.army.mil • NMIMC: https://dataquality.med.navy.mil/reconcile/ • Contact Service POCs re: MTF POC changes

23. Inpatient CCE – What’s Happening? • CCE and CHCS interface not working • Cannot approve SIDR in CHCS • Incomplete SIDR metrics being affected • DRG issues • Additional diagnoses may be re-sequenced • Does not re-sequence Principal Diagnosis (Good!) • Re-sequences ALL CCs (flagged with * or # sign) • M2 - 8 diagnoses / 8 procedures (Ex. injury case, CCE does not allow coder to re-sequence “E” code in top 8) • Principal Procedure should be coder-selected • Follow DoD, CMS, and UHDDS definitions • Assignment of Principal Procedure should not be based solely on most resource-intensive procedure • CCE selects the Principal Procedure

24. Present on Admission (POA) • POA = Present at the time the order for inpatient admission occurs • Deficit Reduction Act of 2005 (DEFRA), signed February 2006 • Collection of POA indicator starts Oct 07 • POA Payment Impact begins Oct 08 • DEFRA impact on CMS Official Coding Guidelines • POA Reporting Guidelines added 1 Oct 06 (Appendix I, 15 Nov 06) • Requires CMS to select 2 or more infectious complications high cost & volume • Requires CMS to exclude non-POA infections from the DRG calculation

25. POA and Documentation • Impact on physician documentation • Impact on (DRG) reimbursement • Collection of new data element • Code one more item with each diagnosis/condition • May be several reporting options, for example: • Y (Yes) • N (No) • U (insufficient documentation) • W (provider unable to clinically make determination) • B (blank, exempt from POA reporting)

26. POA and DoD TBD

27. Summary • We reviewed basic definitions for code selection and sequencing • We discussed documentation -- needs, current and future • We identified some coding deficiencies and gave some suggestions of what to tag for audits • We discussed how the Services process records once received • URLs for each Service • Service POCs to contact