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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 & Evaluation
Medicare/Federal Healthcare Assessment, IPRO
8SOW-NY-TSK3B-05-19
Today’s 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”.
1
Today’s 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
2
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.
3
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).
4
General Training Recap
PEPPER is a report on past administrative claims data.
PEPPER does not identify your hospital’s 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.
5
PEPPER Target Area:
New target area:
Proportion of discharges for claims
with a CC relative to all claims in CC pairs.
6
CMS HPMP Target Area
CMS selected the target areas based on
historical knowledge, experience and
analysis of payment errors.
Demonstration
7
Diagnosis-Related Groups (DRGs)
in a Nutshell
DRGs are classifications of medically related
diagnoses where patients have similar lengths of stay
and resource consumption.
8
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.
9
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 (CC’s).
10
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”.
11
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 > 17 with CC
Relative Wt. 0.8413.
DRG 183 - Esophagitis, Gastroenteritis
& Misc. Digestive Disorder Age > 17
without CC, Relative Wt. 0.5848.
12
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
13
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.
14
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.
15
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.
16
Some Top DRGs in Error: In Depth Analysis
(from Payment Error Cause Analysis)
DRG 182/183 DRG 174/175
DRG 296/297 DRG 141/142
DRG 320/321 DRG 188/189
DRG 089/090 DRG 079/080
17
Top DRGs by Major Diagnostic Category (MDC)
MDC 4 – Respiratory System
079/080 – Respiratory Infections & Inflammations,
Age>17 with or without CC
089/090 – Simple Pneumonia & Pleurisy,
Age>17 with or without CC
MDC 5 – Circulatory System
141/142 Syncope & Collapse with or without CC
18
Top DRGs by MDC
MDC 6 – Digestive System
174/175 GI Hemorrhage with or without CC
182/183 Esophagitis, Gastroenteritis, &
Miscellaneous Digestive Disorders,
>17 with or without CC
188/189 Other Digestive System Diagnoses,
Age>17 with or without CC
19
Top DRGs by MDC
MDC 10 – Endocrine, Nutritional & Metabolic
296/297 Nutritional & Miscellaneous Metabolic
Disorders, Age >17 with or without CC
MDC 11– Kidney & Urinary Tract
320/321 Kidney & Urinary Tract Infections,
Age> 17 with or without CC
20
Interpreting PEPPER
21
DRG 182/183
DRG 182 – Esophagitis, gastroenteritis,
and miscellaneous digestive disorders, age>17,
with complication and co-morbidity.
DRG 183 – Esophagitis, gastroenteritis and
miscellaneous digestive disorders, age>17, 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.
22
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.
23
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.
24
DRG 296/297
DRG 296 – Nutritional and miscellaneous metabolic
disorders, age>17, with CC.
DRG 297 – Nutritional and miscellaneous metabolic
disorders, age>17 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.
25
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.
26
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.
27
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.
28
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 physician’s
judgment.
29
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 >48 hours may indicate,
under-coding and might be sepsis.
Sepsis with LOS < 48 hours may indicate
upcoding and might be UTI.
30
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.
31
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.
32
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.
33
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.
34
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.
35
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.
36
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.
37
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.
38
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.
39
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.
40
DRG 079/080
DRG 079 –Respiratory infections and inflammations,
age >17,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, age>17 without CC.
DRG 089 – Simple pneumonia and
pleurisy, age >17, without CC.
41
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.
42
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).
43
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)
44
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 < 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.
45
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 patient’s 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.
46
General Guideline:
Principal diagnosis is the key factor in a DRG assignment
Determination depends on the circumstances
of the admission and the physician’s 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.
47
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 physician’s 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.
48
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.
49
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 physician
in the final diagnostic statement.
50
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?
51
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?
52
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?
53
HPMP Project Outcome
HPMP CC Pairs Project #2
Pennsylvania
Initiated CC pair DRG project
(DRG 182/183 and 296/297).
54
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.
55
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.
56
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.)
57
Where do we go from here:
Sharing 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.
58
Where do we go from here:
Sharing 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.
59
Where do we go from here:
Sharing 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.
60
Where do we go from here:
Sharing 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.
61
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
62
Contact Information:
Kathy Terry, Ph.D., |
Sr. Director, Data Analysis & Evaluation
Renato L. Estrella, MS, RHIA, Director, HIM
Ravi Moses, CCS, Sr. HIM Validator
Medicare/Federal Healthcare Assessment, IPRO
Email: kterry@nyqio.sdps.org
restrella@nyqio.sdps.org
rmoses@nyqio.sdps.org
Web site(s):
http://pepperinfo.org/
http://jeny.ipro.org/forum display.pup?f=53
8SOW-NY-TSK3B-05-19
