Health Information Management

Carefully examine syncope and collapse denials

HIM-HIPAA Insider, October 18, 2011

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Hospitals reported syncope and collapse (MS-DRG 312) as the top MS-DRG with respect to financial impact due to denials for lack of medical necessity and incorrect coding, according to AHA RACTrac data released in May.

Medical necessity denials for MS-DRG 312 are likely the more frequent culprit, but incorrect coding and sequencing also poses a challenge, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent HIM consultant in Madison, WI. For example, when a physician determines after study that the patient's syncope is related to pneumonia, coders should report pneumonia as the principal diagnosis. Coders should not separately report syncope because it is a symptom that can be associated with pneumonia, according to ICD-9-CM guidelines. This yields MS-DRG 195 (simple pneumonia and pleurisy without CC/MCC) with a relative weight of 0.7096 for FY 2011.
Some coders incorrectly report syncope as the principal diagnosis with pneumonia as a secondary condition, yielding MS-DRG 312, which has a relative weight for FY 2011 of 0.7172.
Review coding guidelines for MS-DRG 312 and how they pertain to signs and symptoms, assignment of principal diagnosis, and sequencing, advises Krauss.
Editor’s note: For more advice, access the article in its entirety in the October issue of Briefings on Coding Compliance Strategies.

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