Health Information Management

News: RACs target respiratory system diagnosis with ventilator support

CDI Strategies, February 17, 2011

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A recent special edition MedLearn Matters article SE1028 outlines four risk areas targeted by the recovery audit contractors (RACs). Of particular concern, according to William E. Haik, MD, FCCP, a pulmonologist and director of DRG Review, Inc., in Fort Walton Beach, FL, is additional scrutiny for respiratory ailments. 

ICD-9-CM guidelines say that code 518.81 (acute respiratory failure) may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital. Don’t be tempted to report respiratory failure—or any other respiratory diagnosis—as principal when it’s clearly not the case, says Haik.

Coders must pay strict attention to physician documentation before assigning a respiratory system diagnosis—particularly respiratory failure—as the principal diagnosis, says Haik. A respiratory system diagnosis with ventilator support triggers MS-DRGs 207–208.
“It’s sometimes very hard to tell whether from the documentation exactly when a patient goes into respiratory failure,” says Kathy DeVault, RHIA, CCS, CCS-P, manager of professional practice resources at the American Health Information Management Association in Chicago. “Were they admitted with it, or were they admitted with an exacerbation of congestive heart failure that progressed into respiratory failure 24 hours later?”
For example, when a patient has pneumonia and heart failure present on admission, don’t assume the pneumonia is principal simply because it would yield a higher-weighted DRG. If the patient receives an oral antibiotic for the pneumonia and an IV with diuretics to treat the heart failure, the heart failure is the principal diagnosis. That’s because the heart failure necessitates admission to the hospital, he explains.
ICD-9-CM guidelines say it’s highly unusual for two diagnoses to equally meet the criteria for principal diagnosis, says DeVault. The guidelines instruct coders to look at both the circumstances of admission and the clinical treatment and diagnostic workup or therapy provided. When documentation is unclear regarding whether acute respiratory failure and another condition are equally responsible for occasioning the admission, coders must query physicians for clarification, she says.
“The government is looking at these [DRGs], and hospitals should be looking at them too,” says DeVault.
Editor’s note: This article was adapted from the January issue of Briefings on Coding Compliance Strategies.

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