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Ensure compliance when reporting cirrhosis and alcoholic hepatitis with an MCC

Association of Clinical Documentation Improvement Specialists, July 8, 2010

MS-DRG 432 (cirrhosis and alcoholic hepatitis with MCC) is one of many MS-DRGs slated for RAC validation audits by HealthDataInsights and Connolly Healthcare, two of the four RACs that have begun targeting hospitals nationwide.

RACs may target this particular MS-DRG for a variety of reasons, says James S. Kennedy, MD, CCS, managing director at FTI Healthcare in Atlanta. Insufficient documentation and sequencing of hepatic encephalopathy will be primary focus areas, he says. So, try to think like RAC auditors when examining the medical record. Asking the following questions about MS-DRG 432 can help ensure compliance.
 
Is the principal diagnosis correct?
As with any diagnosis, it s helpful for coders to understand the clinical details of a condition before sequencing an ICD-9-CM code as a principal diagnosis, says Kennedy. The following five ICD-9-CM codes drive MS-DRG 432 (as well as MS-DRGs 433 and 434) when sequenced as the principal diagnosis, assuming the patient doesn’t also undergo a significant procedure
  • 571.1 (acute alcoholic hepatitis)
  • 571.2 (alcoholic cirrhosis of the liver)
  • 571.3 (unspecified alcoholic liver damage)
  • 571.5 (cirrhosis of liver without mention of alcohol)
  • 571.6 (biliary cirrhosis)
Hepatitis occurs when there is an inflammation of the liver due to a variety of different causes, such as:
  • Drugs (e.g., alcohol or statin drugs)
  • Infections (e.g., hepatitis A, B, or C; infectious mononucleosis; cytomegalovirus; tuberculosis; or HIV)
  • Autoimmune diseases (e.g., lupus or other idiopathic illnesses)
  • Other conditions (e.g., sarcoidosis or non-alcoholic steatohepatitis)
Alcoholic hepatitis refers to hepatitis that is due to alcohol. Unlike other forms of hepatitis, alcoholic hepatitis tends to result in elevated aspartate aminotransferase levels (more than 500 units), whereas alanine aminotransferase levels usually remain normal. However, depending on the severity of the alcoholic hepatitis, the bilirubin and alkaline phosphatase are elevated as well, says Kennedy.
 
Cirrhosis, conversely, is permanent scarring of the liver due to chronic hepatitis. This can occur when a patient persistently consumes alcohol (resulting in alcoholic cirrhosis) or has ongoing chronic persistent or active hepatitis (e.g., from hepatitis C), says Kennedy.
 
Other varieties of acute hepatitis, alcoholic liver damage, and cirrhotic conditions (which have similar signs and symptoms as acute alcoholic hepatitis and cirrhosis) may coexist.
 
“Coders should be careful when assigning and sequencing ICD-9-CM codes in these circumstances and always ensure that physician documentation supports code assignment,” says Kennedy.
 
The following conditions are examples of related conditions that drive different MS-DRGs (i.e., MS-DRGs 441–443 [disorders of the liver except malignancy, cirrhosis, and alcoholic illness]) when assigned as the principal diagnosis:
  • Viral hepatitis (070.xx)
  • Acute and subacute necrosis of the liver (570)
  • Alcoholic fatty liver (571.0)
  • Chronic hepatitis (571.4x)
  • Other chronic non-alcoholic liver disease (571.8)
  • Jaundice, unspecified, not of newborn (782.4)
  • Injury to liver (864.xx)
Does the documentation support the assignment of an MCC?
This can get complicated because physician documentation is often vague, incomplete, or both, says Kennedy. For example, although protein malnutrition is associated with excessive alcoholic consumption, it is not an MCC. However severe protein calorie malnutrition (262) is an MCC, says Kennedy.
 
Abnormal laboratory results, such as low albumin or pre-albumin levels, alone are not enough documentation to allow coders to code severe malnutrition; the physician documentation must support the condition, he explains.
 
Similarly, altered mental status and mental confusion are commonly associated with cirrhosis and alcoholic hepatitis; however, only documented hepatic encephalopathy (572.2) is an MCC.
 
Physicians often document the signs and symptoms of hepatic encephalopathy (e.g., confusion, altered levels of consciousness, or coma) without actually documenting the condition itself, says Jerome Ingrande, RHIT, CCS. Ingrande serves as director of coding compliance at Catholic Healthcare West in Pasadena, CA.
 
“Just because the patient has altered mental status or confusion doesn t mean we can assume he or she has encephalopathy—hepatic or otherwise,” says Ingrande.
 
Coders also can’t assume that hepatic encephalopathy is present when the physician documents encephalopathy without specifically linking it to the chronic liver disorder (e.g., alcoholic hepatitis or cirrhosis), says Ingrande.
 
Similarly, when a physician documents hepatic encephalopathy as an uncertain diagnosis, coders can’t assign the MCC unless it is also documented at the time of discharge, adds Kennedy.
 
Waiting for the discharge summary before coding the record becomes paramount because the information in it could make a big difference in the ultimate assignment of a particular MS-DRG, he explains.
 
Is the principal diagnosis sequenced correctly?
Alcoholic hepatitis is generally an acute condition, which means it could be the reason for the inpatient admission depending on the specific circumstances, says Kennedy. However, there are instances in which it may not be sequenced as the principal diagnosis.
 
For example, a patient is admitted with jaundice and elevated liver enzymes with normal levels of alanine aminotransferase. A physician diagnoses the patient with acute alcoholic hepatitis; however, he or she cites the patient’s severe malnutrition as the reason for the inpatient admission. A query may be necessary to determine which condition prevailed to justify assigning it as the principal diagnosis, says Kennedy.
 
Cirrhosis is a chronic condition and is therefore generally not sequenced as principal. However, the circumstances of the admission, diagnostic approach, and treatment rendered should always be considered, says Kennedy.
 
For example, a patient presents to the ED with jaundice. After an inpatient workup, a physician diagnoses the patient with chronic cirrhosis due to alcoholism. In this case, sequence the cirrhosis as principal because the jaundice is considered a sign and symptom of the disease process, says Kennedy.
 
As a quick rule of thumb, says Kennedy, coders should sequence alcoholic cirrhosis of the liver as the principal diagnosis when the clinical scenario satisfies one of the following three criteria:
  1. The patient is admitted with esophageal varices (i.e., dilated blood vessels within the esophagus due to portal hypertension). The ICD-9-CM index classifies bleeding esophageal varices in cirrhosis of the liver to 571.5 (cirrhosis of the liver without mention of alcohol) followed by manifestation code 456.20 (esophageal varices in diseases classified elsewhere). Note, however, that 456.20 has an instructional note to code first the underlying disease as cirrhosis of the liver (571.0–571.9). This means that 571.2 (alcoholic cirrhosis of the liver) would be coded first, when documented, instead of 571.5.
  1. The patient is admitted primarily for a symptom due to his or her cirrhosis, such as ascites, edema, jaundice, or abnormal liver enzymes that is directly linked to the cirrhosis.
  1. The purpose of the admission is to diagnose the patient s cirrhosis or specifically treat the cirrhosis itself.
Be proactive
To prepare for RAC audits of MS-DRG 432, generate specific reports to obtain a more granular look at the data. The following three reports may be particularly helpful, says Kennedy:
  • All cases for which both alcoholic cirrhosis and hepatic encephalopathy are coded (to ensure that the encephalopathy is sequenced as the principal diagnosis when appropriate)
  • All cases for which alcoholic cirrhosis of the liver—typically a chronic condition—is listed as principal (to ensure that the clinical scenario meets one of the three criteria that were previously listed)
  • All cases for which patients have cirrhosis due to viral hepatitis with hepatic encephalopathy (to ensure that coders didn’t assign a code from the 070 category in addition to 572.2)
“I think [MS-DRG 432] poses the same challenges to hospitals as any other,” says Ingrande. “Now, more than ever, it becomes imperative to have a good, strong, solid documentation improvement program in place.”
 
Editor's Note: This article was first published in the HCPro newsletter Briefings on Coding Compliance Strategies.

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