Health Information Management

Brush up on sequencing as RAC complex reviews get under way

JustCoding News: Inpatient, February 17, 2010

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As Recovery Audit Contractors (RAC) begin to roll out complex reviews and request medical record documentation, compliant coding will continue to take center stage. And although correct coding is vital, sequencing codes is equally as important because it affects MS-DRG assignment and payment.

Sequencing is something with which coders continually struggle, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Marblehead, MA. That's because the circumstances of some admissions are somewhat debatable, leaving a big question mark in terms of which diagnosis is principal, McCall says.

In addition, there are a whole slew of rules to follow. A cursory look at the ICD-9-CM Guidelines for Coding and Reporting reveals a plethora of sequencing requirements, some of which only apply to certain code sets.

It's a lot of information to digest and remember, says McCall. And although encoders can assist with sequencing, coders have the final say in determining which diagnosis is principal. If the patient underwent multiple procedures, coders must also determine which one is principal. The principal diagnosis, principal procedure, and any relevant CCs or MCCs map to a particular MS-DRG (i.e., payment to the hospital).

Know the definition of principal diagnosis
Fundamentally, coders should understand that the Uniform Hospital Discharge Data Set defines the principal diagnosis as the condition found after study to be chiefly responsible for the admission.

"It's not always just about what [the patient] comes in for," says McCall. "They could come in for chest pain and then after study find the patient is actually having [a myocardial infarction (MI)]. It could be an underlying cause to the symptom that might not be clear-cut without performing additional tests."

In some instances, there may be more than one condition that meets the definition. For example, a patient is admitted for uncontrolled diabetes mellitus and acute exacerbation of chronic obstructive pulmonary disease (COPD). A physician treats both conditions equally and provides diagnostic workup and/or therapy for both.

The ICD-9-CM Guidelines for Coding and Reporting state that when two conditions meet the criteria to be assigned as the principal diagnosis, coders may sequence either of the diagnoses first. The only exception to this is when guidance in the alphabetic index, tabular list, or coding guidelines specifically state which diagnosis should be principal. Coders often choose the diagnosis that would yield the higher-weighted MS-DRG, and there is nothing that precludes them from doing so, says McCall.

On the other hand, there may be cases in which two conditions appear to meet the definition when, in fact, they don't, she adds. For example, a patient is admitted for an overdose of cocaine. The patient is also experiencing respiratory failure due to the overdose. Although a coder may be tempted to assume that either the poisoning or respiratory failure could be sequenced first, there is a coding guideline that states otherwise.

The ICD-9-CM Guidelines for Coding and Reporting state that when coding a poisoning or reaction to the improper use of a medication (e.g., wrong dose, wrong substance, or wrong route of administration), the poisoning code is sequenced first, followed by a code for the manifestation.

In the example described above, the manifestation is the respiratory failure, which would be sequenced secondary to the poisoning code from the 900 range, says McCall. \

Understand sequencing for sepsis
These days, RACs are targeting certain MS-DRGs to determine whether they were assigned correctly. Sequencing plays a large role in this because it helps determine the MS-DRG assignment, says McCall.

Most coders won't be surprised by the fact that MS-DRGs 871 (septicemia without mechanical ventilation 96+ hours with MCC) and 872 (septicemia without mechanical ventilation 96+ hours without MCC) appear on the list of issues Connolly Healthcare, the Region C RAC, is auditing, McCall says. She speculates that one of the reasons Connolly could be targeting these DRGs is to ensure that septicemia was correctly sequenced as the principal diagnosis.

“Septicemia can always be difficult to sequence. The guidelines try to be clear-cut, but sometimes they're not when you're trying to code for an actual admission,” says McCall.

Coders must first identify whether the patient had sepsis upon admission. According to the ICD-9-CM Guidelines for Coding and Reporting, if sepsis or severe sepsis is present on admission (POA) and it meets the definition of principal diagnosis, assign the systemic infection code first (e.g., code 038.xx for septicemia). Next, assign code 995.91 for sepsis or code 995.92 for severe sepsis. Lastly, assign a code for the localized infection (e.g., code 486 for pneumonia).

The ICD-9-CM Guidelines for Coding and Reporting also state that when sepsis develops during the encounter and is not POA, coders should assign the systemic infection and sepsis as secondary diagnoses.

It's a common misconception that coders should always sequence the systemic infection first when a patient develops sepsis during an admission, says McCall. “This is exactly why RACs are targeting this,” she explains. “People are assigning the DRG for septicemia when, in fact, the patient may not have had the sepsis when he or she was admitted.”

Coders must recognize whether the systemic infection also meets the definition of a principal diagnosis before sequencing it as the principal diagnosis. In some instances, the localized infection could be principal, says McCall.

Take a look at other sequencing-related issues
Connolly is also targeting several MS-DRGs that indicate operating room (OR) procedures that are unrelated to the principal diagnosis. For example, a patient is admitted for COPD. While the patient is in the hospital, he or she falls and must undergo an open reduction of a hip fracture.

"You're going to have a procedure that doesn't have anything to do with why the patient was admitted. This happens, but it shouldn't happen routinely," says McCall, adding that when the fall and subsequent fracture occurs in a hospital, it could potentially affect MS-DRG assignment and reimbursement because it is considered hospital-acquired.

Not surprisingly, these MS-DRGs have relatively high weights, making them particularly enticing for RACs, says McCall. For example, MS-DRG 981 (extensive OR procedure unrelated to principal diagnosis with MCC) has a relative value weight of 5.0389. MS-DRG 987 (nonextensive OR procedure unrelated to principal diagnosis with MCC) has a relative value weight of 3.4020.

Proper sequencing can help ensure compliance with these and several other procedure-based DRGs, McCall says. In addition to correctly sequencing the principal diagnosis, coders must also identify the principal procedure (i.e., generally the one performed for definitive rather than diagnostic or exploratory purposes). When a provider performs more than one procedure for a definitive purpose, coders should choose the one that most closely relates to the principal diagnosis, according to Coding Clinic, October 1990.

For example, a patient is admitted for an MI and later develops acute cholelithiasis with cholecystitis. A physician performs an open cholecystectomy for the gallstone and an angioplasty to treat the MI. Although both procedures are performed for definitive purposes, the angioplasty is principal because it most closely relates to the MI, the principal diagnosis.

Hospitals can perform a proactive audit by running a list of cases that fall into these MS-DRGs and asking the following questions:

  • Should the case have grouped to this MS-DRG?
  • Was there a diagnosis that truly warranted the procedure performed?
  • Was the principal diagnosis assigned correctly?
  • Was the principal procedure assigned correctly?

Editor’s note: This article was originally published in the February issue of Briefings on Coding Compliance Strategies. E-mail your questions to Contributing Editor Lisa Eramo at

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