Health Information Management

Tip: Put on your clinical hat first, coding shoes second

CDI Strategies, May 28, 2009

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Optimizing MS-DRG sequences could raise RAC concerns
CDI specialists who seek to alter code sequences in order to optimize CC/MCC capture and case mix index could find themselves in trouble with Recovery Audit Contractors (RAC), says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, an independent consultant located in Madison, WI.
 
CDI specialists should focus on clarifying diagnoses and arriving at an accurate clinical picture, not guiding cases down the path of predestined MS-DRGs, says Krauss.
 
“I believe the focus of CDI should be on clarifying working and final diagnoses, and not the optimal MS-DRG,” he says.
 
The following three examples highlight the problem of CDI departments that try to maximize payment instead of documentation accuracy.
 
1. A patient is admitted with shortness of breath and receives BiPAP treatment. The attending physician documents bacterial pneumonia and acute respiratory failure. The CDI specialist stated that pneumonia should be sequenced first and respiratory failure second, which would allow the case to group to a higher weighted MS-DRG (193). The rationale the CDI specialist gave was ICD-9-CM Official Coding Guidelines (Section II, Part B), that states the following:
“In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular list, or another coding guideline does not provide sequencing direction, any one of the diagnoses may be sequenced first.”
However, in this clinical scenario, acute respiratory failure appeared to be the chief circumstance for admission and therefore the principal diagnosis. The case should have grouped to lower weighted MS-DRG 189.
 
Not only does this scenario violate the rules of Coding Clinic, First Quarter 2008 (which provides an example of a patient with aspiration pneumonia and respiratory failure, and states that the principal diagnosis should be based on the circumstances of the admission), but it also lacks clinical credibility, and therefore is an easy target of a RAC contractor.
 
2. A patient is admitted with diverticulitis, dehydration, and acute renal failure. The CDI specialist asked coding staff to assign diverticulitis as the principal diagnosis with acute renal failure and dehydration as secondary diagnoses, since it allowed the case to group to a higher-weighted MS-DRG 391 (relative weight 1.0856). Although the patient was admitted with abdominal pain associated with acute diverticulitis, the primary reason for admission was clinical management of dehydration and prerenal acute renal failure (the patient had oliguria, requiring significant fluid resuscitation beginning with boluses in the emergency room).
 
Properly sequenced (with acute renal failure as the principal diagnosis, and dehydration and acute diverticulitis without bleed as secondary conditions), the case arrived at MS-DRG 684 (renal failure without CC/MCC) with a relative weight of .7305—a lower-weighted but more clinically accurate MS-DRG assignment that is less likely to invite RAC scrutiny.
 
3. A patient diagnosed with simple pneumonia (486.0), acute respiratory failure (518.81), and 410.71 (Subendocardial infarction, initial episode of care) died after a one day stay. The patient was also placed on a ventilator. The CDI specialist presented a case for acute respiratory failure as the principal diagnosis, when 410.71 was appropriate (the patient was admitted for treatment of this diagnosis, which was also the cause of death). The rationale for the CDI specialists’ argument for respiratory failure as principal was that it would result in higher reimbursement, which did not take into account the clinical presentation of the patient and the resulting circumstances of admission.
 
HIM/coding staff should always have the final say on final code assignment and sequencing, but Krauss says CDI specialists who dwell too much on financial impact can create conflicts with coders over final MS-DRG assignments. Although the reality is that CDI specialists have to prove their return on investment to administration, clinical accuracy, not payment, should be the ultimate goal.
 
“This [MS-DRG mindset] gets in the way of their clinical thoughts and creates animosity between coders and CDI specialists,” Krauss says. “CDI specialists feel pressure to optimize and get their case mix up. But they must not allow their quest for optimization to get in the way of their thoughts of documentation. Put your clinical hat on first.”



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