The April edition of CMS’ Medicare Quarterly Provider Compliance Newsletterincludes Comprehensive Error Rate Testing (CERT) findings for inpatient hospital consultations as well as several Recovery Audit findings such as:
- Cholecystectomy as an incorrect secondary diagnosis
- Kidney and urinary tract disorders as incorrect principal diagnosis
- TIA services rendered in a medically unnecessary setting
The quarterly report offers CDI specialists specific analysis regarding trends CMS sees as troublesome or audit worthy in terms of coding and documentation. It outlines the problem area, provides example documentation, and presents tips for how facilities can provide better documentation to resolve the issue.
For example, under kidney and urinary track disorders the newsletter outlines a situation in which a woman from a skilled nursing facility is admitted for a UTI. According to the newsletter, the facility billed for MS-DRG 700 Other Kidney and Urinary Tract Diagnoses w/o CC/ MCC when it should have billed MS-DRG 690 Kidney and Urinary Tract Infections without MCC. CMS explains that:
“The physician documented that the patient has a UTI with chronic indwelling Foley catheter for neurogenic bladder. The term ‘with’ does not clearly state a cause and effect relationship, or indicate the UTI was due to the urinary catheter for coding purposes….
“There was no evidence in the medical record to determine if the physician had been queried as to the cause of the UTI. Therefore, diagnosis code 996.64 (Infection/Inflammatory Reaction Due to Indwelling Urinary Catheter) is being omitted and diagnosis code 599.0 (Urinary Tract Infection) is being sequenced as the principal diagnosis. This change in principal diagnosis results in assignment to MS-DRG 690 (Kidney and Urinary Tract Infections without MCC).”
While the Medicare Quarterly Provider Compliance Newsletter provides important tips CDI specialists need to watch for during regular record reviews, it should be reviewed within the context of the Official Guidelines for Coding and Reporting, Coding Clinic for ICD-9-CM, as well as other regulatory guidance.