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MS-DRGs on OIG radar: Ensure compliant coding

Association of Clinical Documentation Improvement Specialists, December 4, 2008

One year after CMS implemented Medicare Severity DRGs (MS-DRGs), the Office of Inspector General (OIG) released its 2009 Work Plan, in which it stated it will “examine coding trends and patterns under the new system and determine whether specific MS-DRGs are vulnerable to potential upcoding.” The move wasn’t quite unexpected, says Gloryanne Bryant, BS, RHIA, RHIT, CCS, senior corporate director of coding and HIM compliance at Catholic Healthcare West in San Francisco.

“It’s a good message to tell providers to be checking in this area because [the OIG is] going to be checking in this area,” Bryant says. That means coders should understand how their codes affect MS-DRG assignment, and physicians should understand the importance of thorough documentation.

MS-DRG background

In October 2007, CMS made major changes to the IPPS. It expanded the number of DRGs from 538 to 745 and added a new classification: major complication and comorbidity (MCC), a condition that requires significantly more resources than a complication and comorbidity (CC). A complication is an unexpected outcome, and a comorbidity is a condition that coexists with the primary condition during the patient encounter or admission. Examples of MCCs include:

  • Acute and chronic respiratory failure (code 518.84)
  • Coma (code 780.01)
  • Toxic encephalopathy (code 349.82)

Legitimate concerns

With the transition to MS-DRGs came behavioral changes for coders, something the OIG aims to question, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS, a senior coding and chargemaster consultant at QHR in Brentwood, TN. “Have coding patterns changed? Have we changed our patterns in coding to reflect the changes in MS-DRGs?” Krauss says. “A lot of this comes from CMS talking about their concerns.”

Krauss says CMS and the OIG have a legitimate reason to be concerned about potential upcoding. “You need to understand the clinical relevance of these diagnoses,” he says. “I think that portion of the clinical thought process of coders has gone by the wayside. I think it’s a matter of getting the records coded so we can get paid.”

Facilities need to monitor coding staff members to see how well they have adopted new practices since MS-DRGs took effect. After having the same DRG system since the 1980s, facilities will likely find problems that staff members need to address before the OIG does.

“When we had the old system, it was well known and had not been changed since 1982,” Krauss says.

MS-DRG audits

Although the OIG Work Plan makes it imperative to perform MS-DRG audits, these audits should be part of your normal practice, Bryant says.

“It’s an enhancement of what [facilities] probably should have had in place all along,” she says. Facilities should be increasing staff members’ awareness of government focus on MS-DRGs, ensuring that clinical staff members include appropriate documentation in medical records to support the codes and implementing processes to promote practices that follow the MS-DRG guidelines, she adds.

During audits, look for patterns among higher-weighted MS-DRGs. If your audit spots high percentages of MS-DRGs with MCCs, check the documentation supporting the MCC. If there are numerous MS-DRGs with MCCs, it may send the wrong signal to CMS, even if you have all the proper steps in place, good documentation, and good coding to support it, Bryant says.

However, a high percentage of MCCs may be warranted depending on the case-mix index for your hospital or region, Bryant adds.

Make sure you have an audit plan in place to check coding patterns and ensure that documentation supports the codes you report on your claims.

Documentation improvement

Documentation improvement plays a vital role in the transition to MS-DRGs and will be part of the OIG’s review. Clear and thorough documentation is necessary to adequately and appropriately capture CCs and MCCs. Many facilities have realized the increased importance of accurate documentation in the past year and have adopted clinical documentation improvement (CDI) programs to aid in this effort.

“Hospitals have rallied around documentation improvement now that there is additional severity payment,” says Bryant.

Hospitals use CDI programs to review documentation on the medical record floors, looking for documentation that could be clarified. “That greater specificity could change the ICD-9 code, which then could ultimately change the assignment of the MS-DRG grouping,” says Bryant. And that could ultimately affect reimbursement.

If your facility has not already adopted a CDI program, this might be the perfect time to do so in light of the OIG’s Work Plan review. Use the American Health Information Management Association’s practice brief for managing the physician query process to learn about the best techniques for documentation improvement.

To view the practice brief, titled Managing an Effective Query Process, visit www.ahima.org/infocenter/practice_tools.asp#Briefs. Click on “All current practice briefs in chronological order by publication date” and scroll down to the brief.

To view the 2009 OIG Work Plan, go to the ACDIS "Helpful Resources" link, located here http://www.hcpro.com/acdis/resources.cfm, and scroll down to "OIG Home Page." Or, for a direct link to the Work Plan, click here.

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