Unit 2 Overview Reading: Scott, Chapters 1, 2, and 3

(Doc sharing) Post to DB Participate in Option 1 or 2 of seminar Practice:

Green Workbook: p. 52, questions 25 and 26

Writing Assignment: Compare & contrast DRG system with MS-

DRG system.

Unit 2 Overview Describe various payment methods. Apply coding guidelines for proper

payment under the Prospective Payment System (HI250-2)

Code and sequence, keeping in mind quality and reimbursement (HI250-2)

Utilize encoder and grouper software to code and assign an MS- DRG (HI250-4)

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Inpatient Coder Resources Merck Manual

http://www.merckmanuals.com/professional/index.html

CMS website for Prospective Payment Systems http://www.cms.gov/AcuteInpatientPPS/01_over

view.asp#TopOfPage Coding Clinic Medical dictionary Anatomy & Physiology Book Physician Desk Reference

http://www.pdr.net/Default.aspx

Where do I begin? Read the entire record

Face Sheet History & Physical Exam Progress Notes Doctors Orders Lab Results Operative Notes ER Notes, if applicable Discharge Summary

Take notes Write all diagnoses Write all procedures

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UHDDS Inpatient data is collected based on the requirements of the

Uniform Hospital Discharge Data Set (UHDDS) Med Record/Control/Encounter number Date of Birth Gender Race Ethnicity Residence Hospital Identification Admission and discharge dates Physician identification Discharge Disposition Payer

All of the data collected is used to generate the UB-04 Claim Form

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UB – 04 Form

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FL67 Diagnosis Codes

Field 67 is for the principal diagnosis. Fields 67a-q are for subsequent diagnoses

Each diagnosis field has 8 positions. The 8th position is for the POA (Present on Admission) indicator

Source of the information These diagnosis codes should

be assigned after review of medical record documentation and in accordance with official coding guidelines and entered by the HIM department

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Admitting Diagnosis Describes patient’s diagnosis at the time

of admission Required on all inpatient claims Most often a symptom One admitting diagnosis is reported

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Admitting Diagnosis vs. Principal Diagnosis Examples Admit: Gastrointestinal bleeding – 578.9 Principal: Acute duodenal ulcer with

hemorrhage – 532.00

Admit: Acute cholecystitis – 575.0 Principal: Acute cholecystitis with

cholelithiasis – 574.00

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Principal Diagnosis (PDX) The condition established after study to

be chiefly responsible for admission of the patient to the hospital.

Dependent on the circumstances of the admission

Dependent on coding directives in ICD-9-CM

Dependent on official coding guidelines

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Additional Diagnosis Conditions that coexist at the time of admission or

develop subsequently or affect patient care for the current hospital episode

Affect patient care defined as: Clinical evaluation Therapeutic treatment Further evaluation Extends LOS Increase nursing care and/or other

monitoring

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Additional Diagnosis Previous conditions – Code diagnoses that are on the final diagnostic

statement like the discharge summary or the face sheet. History codes may be used a secondary codes if the condition or family history has an impact on current care or influences treatment.

Abnormal findings – Not reported unless the provider indicates their clinical significance. If findings are outside of normal range and the provider has ordered additional tests to evaluate the condition, querying the provider is appropriate.

Uncertain diagnosis – Probable, suspected, likely, questionable, still ruled out, or similar terms indicating uncertainty, code the condition as id it existed or was established. This bases for this guideline are the diagnostic workup, arrangements for further workup or observation. This only applies to inpatient coding only for short-term, acute, long-term care and psych hospitals.

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Present on Admission POA indicator is assigned to principal and

secondary diagnoses Present on Admission Reporting Guidelines can be

found in the ICD-9-CM Coding Guidelines (pg. 95) Status Indicators

Y = present at the time of inpatient admission N = not present at the time of inpatient admission U = documentation is insufficient to determine if

condition is present on admission W = provider is unable to clinically determine

whether condition was present on admission or not

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Assign the POA Question #1 The physician documents in the patient

history that the patient is admitted for acute and chronic bronchitis. The condition is coded to 466.0 and 491.9. What are the POA indicators for the acute and chronic bronchitis?

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Assign the POA Question #2 A patient with a severe cough and

difficulty breathing is admitted from a private physician’s office. Following hospital work-up, a malignant neoplasm of the patient’s lung is diagnosed. What is the POA indicator assignment for the malignant neoplasm of the lung?

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Assign the POA Question #3 A patient is admitted for treatment of a

lacerated spleen as a result of an automobile accident. Documentation also indicates that the patient has sickle cell disease. Two days following admission, a diagnosis of sickle cell crisis is made and the patient is treated. This condition is coded to 282.62. What is the POA indicator for the sickle cell disease with crisis?

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Assign the POA Question #4 A patient is admitted with a diagnosis of

cough and fever, with a subsequent diagnosis of aspiration pneumonia. The physician has documented in the patient history and discharge summary that the patient has suffered a previous CVA with residual dysphagia. The dysphagia is reported with code 438.82. What is the POA indicator for the dysphagia?

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Assign the POA Question #5 A patient is admitted into day surgery unit

for elective repair of an inguinal hernia. Following the procedure, the patient develops acute exacerbation of COPD. The patient is subsequently converted to inpatient status. The code for the acute exacerbation of COPD is 491.21. What is the POA indicator for the COPD?

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FL74 Principal Procedure Code and Date

This is the ICD-9-CM code that identifies the principal IP procedure performed at the claim level

FL74a-e are for all significant procedures performed in addition to the principal procedure

Source of the information These diagnosis codes should

be determine and entered by the HIM department

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Principal Procedure Performed for definitive treatment (rather than

diagnostic or exploratory purposes) or one that is necessary to care for a complication

If two or more procedures appear to meet the definition, the one more related to the principal diagnosis is designated as the principal procedure

If both are related, the one most resource intensive or complex

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Significant Procedure Surgical in nature Anesthetic risk Procedural risk Specialized training

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Procedures not coded by HIM Do not code procedures that fall within

the code range 87.01 through 99.99 Exceptions:

87.51 - 87.54 Cholangiograms 87.84 and 87.86 Retrogrades, urinary systems 88.40 - 88.58 Arteriography and angiography 92.21 - 92.29 Radiation therapy 94.24 - 94.27 Psychiatric therapy 94.61 - 94.69 Alcohol/drug detoxification and

rehabilitation

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Procedures not coded by HIM 96.04 Insertion of endotracheal tube 96.70 – 96.72 Mechanical ventilation 98.51 – 98.59 ESWL 99.25 Chemotherapy

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Hospital Chargemaster A hospital chargemaster, also known as

a chargemaster or CDM, contains the prices of all services, goods, and procedures for which a separate charge exists. It is used to generate a patient’s bill.

Services (procedure codes) that are captured by the chargemaster, are not coded by the inpatient coder.

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Discharge Status Also known Status on the UB-04 Indicates where the patient went after

discharge from the hospital If long term care, psych, home health,

rehab, cancer hospital, children’s hospital and SNF may impact payment to hospital for transfer MS-DRGs

Transfer to short term acute care impact payment regardless of MS-DRG

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FL17-Discharge Status

This form identifies the discharge status of the patient related to the dates of services covered by the claim

Some options are: 01-D/C home 07-Left AMA 30-Still patient

Source of the information The discharge status should be

documented in the nursing notes and entered by HIM

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Assigning DRG’s Age of the patient Sex Discharge Status Diagnosis Codes with POA Indicator

Principal Diagnosis Secondary Diagnosis (MCCs or CCs)

Procedure Codes Principal Procedure Significant Procedures

MS-DRG Optimization Optimization is the process of striving to obtain optimal

reimbursement or the highest possible payment to which the facility is legally entitled on the basis of coded data supported by documentation in the health record. Not all MS-DRGs are affected by the presence of a secondary diagnosis. It can be determined by the MS-DRG title whether the MS-DRG is affected by the absence or presence of a CC or MCC. Example: MS-DRG 193, Simple pneumonia and pleurisy with MCC,

1.4753 MS-DRG 194, Simple pneumonia and pleurisy with CC,

1.0124 MS-DRG 195, Simple pneumonia and pleurisy without

MCC/CC, 0.7073

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MS-DRG Optimization In the previous example, one way to optimize MS-DRG 195

would be to review the record further for documentation of a secondary diagnosis that would qualify for a CC or MCC. Other ways to optimize in the above case would be to review the record for the following: An organism that is responsible for the pneumonia Respiratory neoplasm Septicemia Mechanical ventilation Opportunistic lung infection in a patient with HIV Tracheostomy with mechanical ventilation over 96 hours

 Remember to optimize, supporting documentation must be included in the health record, and the definition for principal diagnosis must be met.

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Physician Query Process Query provider (physician or other qualified

healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g., present on admission indicator).

Query Example 63 y/o patient was admitted with weakness, lung cancer,

and not eating. The physical exam indicates dry skin with poor turgor. Lab revealed and elevated BUN and other electrolyte abnormalities. Physician order IV therapy and Medication Administration Record documents IV fluids at 100 cc/hr for two days.

Consider: Is a query (ies) necessary? What clinical indicators would you list on the query form? How would you word the query to the physician?

THE ENDQuestions