Health Information Management

FY 2013 IPPS final rule: How will the changes empower coders to improve compliance?

JustCoding News: Inpatient, September 26, 2012

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 Coders play a crucial role in ensuring compliance, and the FY 2013 IPPS final rule, released August 1, gives them many reasons to showcase their skills. 

For FY 2013, CMS added the following two conditions to the list of HACs:
  • Surgical site infection following cardiac implantable electronic device
  • Iatrogenic pneumothorax with venous catheterization
CMS also added the following two codes to the existing vascular catheter-associated infection HAC category:
  • 999.32, bloodstream infection due to central catheter
  • 999.33, local infection due to central venous catheter
How coders can take charge: Coders can't make assumptions when coding surgical site infections, says William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Fla. “Coders aren’t supposed to assume a complication ­following a procedure. It must be documented as being due to or resulting from a procedure,” he says.
Coders should also exercise care when reporting pneumothorax. “Coders shouldn’t assume that a condition that’s present radiologically is clinically significant for reporting purposes. It must be documented by the physician, but it must also meet the rules for reporting additional diagnoses,” says Haik.
More generally, coders should review clinical guidelines for HACs to determine whether conditions are present on admission (POA) or whether they developed after admission, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent HIM consultant in Madison, Wis. Krauss refers coders to CMS evidence-based guidelines for HACs.
CC and MCC changes
Although CMS didn’t add any MCCs or delete any CCs, the agency did change some malnutrition codes. CMS validated that malnutrition, unspecified, is a CC, and also determined through data analysis that mild and moderate nutrition should be CCs.
CMS also finalized the move of code 584.8 (acute renal failure with a specified pathological lesion) from an MCC to a CC. Finally, CMS decided not to include code 428.0 (congestive heart failure, unspecified) as a CC. It also decided not to designate 440.4 (chronic total occlusion of arteries of the extremities) as an MCC or CC.
How coders can take charge: Coders must enhance their clinical knowledge and query physicians when necessary, says Krauss. Questioning diagnoses that are documented-as well as those that appear to be omitted-isn't contrary to coding guidelines, but rather a necessity in today's compliance-driven healthcare environment, he says.
Understanding clinical indicators is paramount. “Malnutrition is a perfect example,” says Haik. “Coders sometimes mistakenly look at the biometrics, such as the albumin or prealbumin levels, and say, ‘Okay, these are consistent with malnutrition.’ But malnutrition is not a laboratory test-it's a clinical setting.” Coders should look at these values in the larger context of whether the patient has cancer, an inability to absorb protein properly, or a chronic illness that causes protein loss (e.g., intestinal fistula or Crohn's disease), for example, he says.
“In other words, there must be a clinical setting to which you can apply these biometrics,” says Haik. The physician must also address the malnutrition (e.g., request a nutritional consultation) before coders can report it.
Note that the American Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition published detailed clinical criteria providers can use when documenting malnutrition severity levels. The guidelines appeared in the May 2012 Journal of the Academy of Nutrition and Dietetics.
Coders should note that the codes they report can affect future CC and MCC designations.
Chronic total occlusion of an artery of the extremities, a condition in which plaque builds up in a patient’s arteries over time, is one example. This condition, which requires increased resources, can progress to other conditions such as gangrene or ulcerations of the leg, says Haik. Patients often require arteriograms and other procedures to remove the occlusion.
“It’s a fairly low-volume diagnosis, but as we get more statistics on it, it could possibly move up or down, although it’s closer to an MCC as it stands right now,” he says.
Coders are in a perfect position to advocate for greater specificity that will lead to improved quality of care, says Haik. Consider unspecified congestive heart failure. This condition isn’t a CC or MCC, and it’s also a nonspecific code. Coders should encourage physicians to document whether the congestive heart failure is diastolic or systolic. These terms are more specific, and both conditions are also CCs or MCCs, depending on whether the condition is further specified as acute, chronic, or acute on chronic.
“One day we may be able to treat the diastolic heart failure differently than a systolic heart failure. Right now, the treatments are not very different. We want better data for multiple reasons-not just payment, but also for research, treatment, and quality of care,” says Haik.
DRG changes
When coders report a principal diagnosis of influenza with pneumonia (code 487.0) and a secondary diagnosis of certain types of more specified pneumonia, cases will map to MS-DRGs 177-179 rather than lower-weighted MS-DRGs 193-195. Types of pneumonia reported as secondary diagnoses that will trigger the reassignment include:
  • 482.0, pneumonia due to Klebsiella pneumoniae
  • 482.1, pneumonia due to Pseudomonas
  • 482.40, pneumonia due to Staphylococcus, unspecified
  • 482.41, methicillin susceptible pneumonia due to Staphylococcus aureus
  • 482.42, methicillin resistant pneumonia due to ­Staphylococcus aureus
  • 482.49, other Staphylococcus pneumonia
  • 482.81, pneumonia due to anaerobes
  • 482.82, pneumonia due to Escherichia coli [E. coli]
  • 482.83, pneumonia due to other gram-negative bacteria
  • 482.84, pneumonia due to Legionnaires’ disease
  • 482.89, pneumonia due to other specified bacteria
How coders can take charge: “The take-home message for the coder is to look at the cultures and treatments to see if there’s a more specified pneumonia associated with that influenza so it can group to a more appropriate DRG,” says Haik. Evaluate the sputum and blood cultures and the treatment, and then query whether the physician can identify the specific bacterial etiology of the pneumonia, he says. In particular, coders should be on the lookout for staphylococcal pneumonia that physicians often treat with Zyvox® or vancomycin. “We employ these drugs only for staphylococcal ­pneumonia,” he says.
Coders can ensure correct MS-DRG assignment by reviewing codes suggested by the encoder prior to finalizing the record, says Krauss. When two conditions meet the definition of principal diagnosis, medical necessity should be the tie-breaker-not necessarily the code that results in a higher-paying DRG. By focusing on medical necessity, coders can help avoid countless costly denials, he says.
“My philosophy is that we code for accuracy,” says Krauss. “Whatever DRG is assigned is what's assigned. When we try to shift or move DRGs, that’s what gets coders and CDI [clinical documentation improvement] folks into trouble. Focusing on the accuracy of the coding ensures that the MS-DRG assignment is accurate.”
As of October 1, CMS will reduce payments to certain hospitals with excess readmissions. CMS generally defines a readmission as an admission to an acute care hospital paid under the IPPS within 30 days of a discharge from the same or another acute care hospital. The 30-day readmission measures, which were finalized in the FY 2012 IPPS final rule, include acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN).
CMS will calculate a hospital’s excess readmission ratio for AMI, HF, and PN with three years of discharge data and a minimum of 25 cases. In FY 2013, the agency will base the ratio on discharges occurring July 1, 2008, through June 30, 2011. The ratio will measure a hospital’s readmission performance compared to the national average for the hospital’s set of patients with that applicable condition.
How will the ratio affect payment?
CMS will apply a readmissions adjustment factor to a hospital’s base operating DRG payment. The agency expects the program will result in a $270 million decrease in overall payments to hospitals.
How coders can take charge: Coders play an important role in reporting readmissions accurately, says Krauss. Principal diagnosis assignment affects data reporting. For example, a patient is admitted to the hospital with congestive heart failure. The patient is discharged, but presents to the ED with congestive heart failure and chronic obstructive pulmonary disease (COPD) two weeks later. ­Coders must pay close attention to whether the congestive heart failure or COPD is the reason, after study, for the actual admission, Krauss explains. Readmission for the same clinical diagnosis within 30 days implies an ineffective discharge plan with potentially problematic postacute care arrangements and placements.
Quality-driven initiatives
Each year, CMS updates the list of quality measures ­included in the Hospital Inpatient Quality Reporting program. The program currently includes 72 measures. For FY 2015, CMS will reduce the number of quality measures to 59, and it will add one measure for FY 2016. Although participation in the program is voluntary, nonparticipating hospitals incur a financial penalty.
The Hospital Value-Based Purchasing (VBP) program, which CMS also updates annually, is another way in which it promotes quality care. FY 2013 marks the first year that VBP payment implications will be effective. CMS will adjust payments based on how hospitals perform or improve their performance on a set of quality measures.
The FY 2013 IPPS final rule also establishes a framework for two new quality reporting programs that will apply to PPS-exempt cancer hospitals, psychiatric hospitals, and psychiatric units. It also establishes requirements for the Ambulatory Surgical Center Quality Reporting program.
How coders can take charge: Coders must understand that the codes they ­report ­affect a hospital’s quality measures, says Krauss. “The data that’s used for these measures comes from coding and claims data,” he says.
In some cases, physicians may hinder reporting ­certain conditions that could have a negative effect on quality measures, says Haik. Cellulitis and blood clots are two examples of conditions for which clinical indicators may be present in the record even though the attending physician may resist documenting the diagnoses or answering queries for clarification. Coders must feel comfortable reporting these occurrences to a manager or physician advisor, he says.
Editor's note: This article originally appeared in the October issue of Briefings on Coding Compliance Strategies. Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at

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