Making Inpatient Audits FAIR Again

Transcription

1 2016 GHIMA Annual Meeting & Exhibit "Charting the Course...A World of Opportunities." Making Inpatient Audits FAIR Again By: Sabrina A. Clark, RHIA HRA Strategies, LLC OUTLINE Inpatient Coding Audits Historical Inpatient Coding Audits Methods, Performers, Guidelines and Expectations Past Audits Recent Years Audits Present Audits Future Audits What can we do to help? Association Support What can we do to Avoid Audits? 1

2 OUTLINE Inpatient Coding Audits, continued What can we do to Avoid Audits? NOT MUCH Damage Control Pre bill Audits (benefits) Post bill Audits (benefits) REBILL CHANGES found within Rebill Window Why? Possible CMI changes for the future Reduce Target Size OUTLINE Inpatient Coding Audits, continued How do you handle Recommended DRG Changes? From within facility Audits? From external contractor Audits? Recent Contractor Suggested DRG Change Examples Your opinion My opinion How would you handle the changes? Common Coding Guidelines for Current RAC Changes You Can HELP!!! Methods, Performers, Guidelines Historical Inpatient Coding Audits Methods, Performers, Guidelines and Expectations Past Audits Coding Clinics, QIOs Recent Years Audits Coding Clinics, RACs, QIOs Present Audits Multiple Referenced Guidelines Every Payer Future Audits? 2

3 Damage Control We cannot avoid Recovery Audits Damage Control Pre bill Audits (benefits) Post bill Audits (benefits) REBILL CHANGES found within Rebill Window Why? Possible CMI changes for the future Reduce Future Audit Size Antineoplastic Pancytopenia (MCC) Patient with a history of lymphoma and Antineoplastic Pancytopenia D (MCC) is admitted for treatment of Acute Pancytopenia. Oncology Consultation notes that Pancytopenia was secondary to Chemotherapy, patient is recovering. Discharge Summary notes Pancytopenia secondary to Lymphoma RAC (recovery audit contractor) not CMS, Changed the Antineoplastic Pancytopenia D (MCC) to Other Pancytopenia D (CC) REASONING Conflicting Physician Documentation Encephalopathy (MCC) Diabetic patient presented to the Emergency Room diaphoretic, nonverbal, and not able to follow directions. While patient was being assessed for a CVA, it was noted that the patient s blood sugar was in the low 40 s. Encephalopathy secondary to hypoglycemia was documented on the ER report, the H&P, progress notes and the Discharge Summary. RAC (recovery audit contractor) not CMS, deleted the secondary diagnosis code for Encephalopathy. REASONING Encephalopathy is inherent in the disease 3

4 Encephalopathy Patient admitted with confusion which was diagnosed as encephalopathy and well documented. Within the Discharge Summary, the physician notes that the encephalopathy was probably secondary to colitis. RAC (recovery audit contractor) changed encephalopathy to other disease of the brain Sepsis Vs Encephalopathy Patient presented with sepsis and encephalopathy due to urinary tract infection versus sepsis. Sepsis is sequenced as the Principal Diagnosis RAC (recovery audit contractor) Re sequenced the principal diagnosis to encephalopathy referencing the symptom followed by comparing diagnoses. NOTE: This guideline has been eliminated Sepsis as Pdx Very Ill appearing, hypotensive patient with history of Cancer, Pancytopenia, Acute CHF and renal Failure admitted with Diagnosis of Sepsis. Sepsis is well documented throughout the record. H&P, Progress Notes, D/C Summary. RAC (recovery audit contractor) not CMS, deleted Sepsis, changed Pdx to CHF. No specifications were given, no clinical reasoning presented such as in medical necessity cases. REASONING Auditor noted, because they felt it was not clinically present. 4

5 Sepsis as Pdx RAC (recovery audit contractor) deleted Sepsis, changed Pdx to altogether. This was not a review for medical necessity but for DRG Validation. REASONING Auditor noted, because there was no clinical evidence or organ failure Post op Blood Loss Anemia Patients generally develop blood loss anemia after surgeries where blood loss is unavoidable Well documented as expected post op blood loss anemia RAC (recovery audit contractor) changed the post op blood loss anemia to?preop anemia because of the term expected Anticipated Conditions Coding Guidelines,,, Respiratory Failure A Chronic Respiratory Failure patient (on 4L O2 at home) presents in acute respiratory failure due to CHF and Gram Negative Pneumonia and COPD Pneumonia was noted in the record as gram negative and was sequenced as the Pdx. PNA was noted in the D/C summary but not as ( ). RAC changed (Gram ) PNA to PNA, NOS for reasons of conflicting physician documentation 5

6 Respiratory Failure/CHF Patient admitted with new onset of CHF with Pulmonary Edema and Acute Respiratory Failure. Cardiac Studies were performed confirming New Onset of CHF and CHF was sequenced as Pdx RAC changed Pdx to Acute Respiratory Failure because it was the condition necessitating the admission RECENT DRG CHANGES Coding Clinic, Third Quarter 2011 Pages: 3-4 Effective with discharges: September 23, 2011 Individuals who are overweight, obese or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider. In addition, the body mass index (BMI) code meets the requirement for clinical significance when obesity is documented. Refer to Coding Clinic, Third Quarter 2007, pages 13-14, for additional information on coding chronic conditions. RECENT DRG CHANGES CONT Coding Clinic, 1994 Question: A patient with gallstone pancreatitis is admitted for an elective laparoscopic cholecystectomy and percutaneous liver biopsy. What is the appropriate diagnostic code assignment for gallstone pancreatitis? Answer: Assign code 577.1, Chronic pancreatitis, as the principal diagnosis. Assign code , Calculus of bile duct without mention of cholecystitis, with obstruction, as an additional diagnosis. Assign procedure codes 51.23, Laparoscopic cholecystectomy, and 50.11, Closed percutaneous [needle] biopsy of liver. Coding Clinic, Second Quarter 1996 Question: If a patient has gallstone pancreatitis and documented acute cholecystitis and/or cholelithiasis, would this be the principal diagnosis over the pancreatitis? Answer: Sequencing depends upon the circumstances of the admission. 6

7 RECENT DRG CHANGES CONT Uncertain Diagnosis If the diagnosis documented at the time of discharge is qualified as probable, suspected, likely, questionable, possible, or still to be ruled out or other ICD 10 CM Official Guidelines for Coding and Reporting FY 2016 Page 100 of 115 similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. RECENT DRG CHANGES CONT A. Codes for symptoms, signs, and ill defined conditions Codes for symptoms, signs, and ill defined conditions from Chapter 18 are not to be used as principal diagnosis when a related definitive diagnosis has been established. C. Two or more diagnoses that equally meet the definition for principal diagnosis In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first. E. A symptom(s) followed by contrasting/comparative diagnoses GUIDELINE HAS BEEN DELETED EFFECTIVE OCTOBER 1,