Revenue Cycle

Tip: Stay on top of common coding pitfalls

Recovery Auditor Report, December 24, 2008

Although coding denials did not remain the focus by the end of the demonstration project, and medically unnecessary settings appeared to have taken its place, accurate coding will continue to be one of the areas the permanent RACs will review as part of their continuing audits. Therefore, a good proactive program that ensures accurate coding and appropriate medical settings and services is essential.
The DRGs/procedure codes listed below were the most frequently cited for coding errors:
  • DRG 186–187—Pleural effusion with complication/comorbidities(CC) or major CC (MCC)
  • 86.22—Debridement
  • DRG 813—Coagulation disorders
  • DRG 870–871—Septicemia
  • 54.51 and 54.50—Lysis of adhesions
  • DRGs 981–989—For operating room procedures unrelated to the principal diagnosis
The DRGs listed below were most frequently associated with medical necessity and one-, two-, and three-day admissions denials:
  • DRG 551—Medical back problems
  • DRG 313—Chest pain
  • DRGs 377–379—Gastrointestinal hemorrhage with MCC, CC or without CC/MCC
  • DRGs 640–641—Nutritional and miscellaneous metabolic disorders with MCC or without MCC (e.g. dehydration)
  • DRG 291–293—Heart failure and shock with MCC, with CC or without CC/MCC (e.g. congestive heart failure)
  • DRG 689–690—Kidney and urinary tract infections with MCC or without MCC
  • DRG 682–684—Renal failure with MCC, with CC or without CC/MCC
  • DRG 811–812—Red blood cell disorders with MCC or without MCC
  • DRG 286–287—Circulatory disorders except AMI, with cardiac catheterization with MCC or without MCC
  • DRG 264—Other circulatory system operating room procedures
  • DRG 190–192—Chronic obstructive pulmonary disease (COPD) with MCC, with CC or without CC/MCC
  • DRG 166–168—Other respiratory system operating room.procedures with MCC, with CC or without CC/MCC (e.g. transbronchial lung biopsy)
  • DRG 222–227—Cardiac defibrillator implantations with or without cardiac catheterization   
This list is not all-inclusive. Any DRGs, diagnoses, procedure codes, or medical necessity issues that have been identified as problems for the hospital should be included in proactive reviews for documentation improvement and consistent coding compliance.

Editor’s note: This tip is excerpted from HCPro, Inc.’s new book, The HIM Director's Guide to Recovery Audit Contractors, by Jean S. Clark, RHIA. For more information on the book, click here.


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