Health Information Management

RAC begins complex DRG validation audits: Medical record documentation requests imminent

HIM-HIPAA Insider, December 8, 2009

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Connolly Healthcare has announced the first issues approved for complex RAC review, so providers in several RAC Region C states could begin seeing medical record documentation requests at any time. Connolly is not yet reviewing for medical necessity.
 
The DRG-validation issues are approved for the following states: Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, and Texas.
 
According to the Connolly Web site, the 24 approved DRG validation issues are:
  • MS-DRG 163. Major chest procedures with major complication/comorbidity (MCC)
  • MS-DRG 164. Major chest procedures with complication/comorbidity (CC)
  • MS-DRG 165. Major chest procedures without CC/MCC
  • MS-DRG 166. Other respiratory system OR procedures with MCC
  • MS-DRG 167. Other respiratory system OR procedures with CC
  • MS-DRG 168. Other respiratory system OR procedures without CC/MCC
  • MS-DRG 207. Respiratory system diagnosis with ventilator support 96+ hours
  • MS-DRG 255. Upper limb and toe amputation for circulatory system disorders with MCC.
  • MS-DRG 329. Major small and large bowel procedures with MCC
  • MS-DRG 330. Major small and large bowel procedures with CC
  • MS-DRG 331. Major small and large bowel procedures without CC/MCC
  • MS-DRG 372. Major gastrointestinal disorders and peritoneal infections without CC/MCC
  • MS-DRG 386. Inflammatory bowel disease with CC
  • MS-DRG 394. Other digestive system diagnoses with CC
  • MS-DRG 432. Cirrhosis and alcoholic hepatitis with MCC
  • MS-DRG 813. Coagulation disorders
  • MS-DRG 871. Septicemia without mechanical ventilation 96+ hours with MCC
  • MS-DRG 872. Septicemia without mechanical ventilation 96+ hours without MCC
  • MS-DRG 981. Extensive OR procedure unrelated to principal diagnosis with MCC
  • MS-DRG 982. Extensive OR procedure unrelated to principal diagnosis with CC
  • MS-DRG 983. Extensive OR procedure unrelated to principal diagnosis without CC/MCC
  • MS-DRG 987. Nonextensive OR procedure unrelated to principal diagnosis with MCC
  • MS-DRG 988. Nonextensive OR procedure unrelated to principal diagnosis with CC
  • MS-DRG 989. Nonextensive OR procedure unrelated to principal diagnosis without CC/MCC

"I can certainly see why most of the DRGs Connolly is targeting are surgical DRGs," says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro.

A patient may undergo a procedure for a variety of different reasons, so providers would group an admission to a particular DRG based off the combination of the principal diagnosis, any present accompanying additional diagnosis (i.e., CCs or MCCs), and the principal procedure, McCall explains. Therefore, if the provider reports an incorrect code as the principal diagnosis, the assigned DRG may not be correct.

Similarly, principal procedures are by definition definitive in nature (as opposed to diagnostic or exploratory procedures), she says. So if two procedures meet the criteria, then the provider should select the one most closely related to the principal diagnosis, per the October 1990 AHA Coding Clinic.

This concept is also pertinent for the issues involving procedures unrelated to the principal diagnosis DRGs, she notes. "These DRGs have high relative weights and should be encountered infrequently. They have long since been a target for payers because of their high weights, as well as the unlikelihood of their occurrence, especially these days with admission criteria and procedures being done more commonly in the outpatient setting."

For example, consider the following weights for 2010 of some of the issues Connolly is targeting:
  • MS-DRG 981, Extensive OR procedure unrelated to principal diagnosis with MCC: Weight 5.0389
  • MS-DRG 982, Extensive OR procedure unrelated to principal diagnosis with CC: Weight 2.8954
  • MS-DRG 983, Extensive OR procedure unrelated to principal diagnosis without CC/MCC: Weight 1.8072
  • MS-DRG 987, Nonextensive OR procedure unrelated to principal diagnosis with MCC: Weight 3.4020
  • MS-DRG 988, Nonextensive OR procedure unrelated to principal diagnosis with CC: Weight 1.7836
  • MS-DRG 989, Nonextensive OR procedure unrelated to principal diagnosis without CC/MCC: Weight 1.0358
Septicemia and ventilation DRGs
"Septicemia is a diagnosis that has been problematic for a long time because coders often misunderstand the ICD-9 Guidelines for Coding and Reporting as it pertains to the sequencing of the assigned codes," says McCall. “This is especially true with sepsis as it relates to septicemia and other underlying infections that can cause sepsis. Many read the guidelines as saying septicemia is always the principal diagnosis when in fact that may not be the case depending on the documentation.”

For example, in an admission when the patient has sepsis due to an underlying infection (e.g., pneumonia) the sequencing could change depending on whether the physician’s documentation states that the patient also had septicemia, she explains. The instructional note for code 995.91 (sepsis) states that coders should sequence the underlying infection first, which could be pneumonia (code 486) or septicemia (code 038.xx), depending on the circumstances surrounding the admission. 

“Ventilation is also tricky,” says McCall. “This is another area that has specific guidelines on when it can be reported, and coders have to deal with the time-counting aspect as well. And for the medical DRGs, it makes sense to target those with CCs or MCCs like cirrhosis and alcoholic hepatitis because a common symptom and associated sign is mental confusion, which could be inaccurately coded as an encephalopathy (348.xx are MCCs) or malnutrition (severe protein calorie is a MCC),” McCall says.
 
Connolly has also provided descriptions of each of the new issues, along with references for providers who are looking to find more information on any of the topics.

Editor's note: It has been brought to our attention that one of the newly listed issues (MS-DRG 372. Major gastrointestinal disorders and peritoneal infections without CC/MCC) may contain an error as it is listed on Connolly's RAC Web site. The description for MS-DRG 372 is actually “Major gastrointestinal disorders and peritoneal infections with CC,” whereas the description provided applies to MS-DRG 373. It is unclear at this time which of the two, either the DRG number or description, has actually been approved for review.



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