Financial Implications of Coding Inaccuracies in Patients Undergoing EVAR

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Evan Hodge
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Giles, MD University of Florida, College of Medicine

1 Financial Implications of Coding Inaccuracies in Patients Undergoing EVAR { Suniah Ayub, MD, MPH; Salvatore Scali, MD; David Bielick, MS; Thomas Huber, MD, PhD; Javairiah Fatima, MD; Kristina Giles, MD University of Florida, College of Medicine Division of Vascular Surgery and Endovascular Therapy, Gainesville, FL

2 Disclosures No Financial Disclosures

Costs associated with EVAR From 2003-2013, 78%

3 Costs associated with EVAR From , 78% decrease in the number of open repairs [1]. Study of non-ruptured EVARs found a net loss of $4015 per case [2]. Endografts accounted for 52% of total cost

4 Medicare Coding & Billing DRG (Diagnosis Related Group) Groups similar clinical conditions / procedures during a hospitalization MS-DRG (Medicare Severity-DRG) Accounts for SOI and resource consumption Three levels of severity: MCC, CC, Non-CC Factors that affect Medicare Reimbursement DRG relative weight Teaching Hospitals Local market conditions / wage index Disproportionate Share Hospitals Case Mix Index

5 Process of Coding MS-DRGs

6 MS-DRG Codes Used in our study (effective until ) 237: Major Cardiovascular Surgical Procedure w/ MCC/CC 238: Major Cardiovascular Surgical Procedure w/o MCC/CC 252: Other Vascular Surgical Procedure with MCC 253: Other Vascular Surgical Procedure with CC 254: Other Vascular Surgical Procedure without CC/MCC

7 Study Objectives Verify the appropriateness of MS-DRG assignment for elective infrarenal EVARs Assess inpatient outcomes that could be potential cost-drivers Review actual hospital reimbursement Perform a cost analysis of the potential lost reimbursement secondary to MS-DRG miscoding

8 Methods Coding & Outcomes Retrospective review of elective infrarenal EVARs at UF from 12/16/2010 to 10/1/2015 Reviewed intraoperative / inpatient outcomes Classified according to standard or complex Charts reviewed for miscoding Class MS- Definition DRG Standard 238 major cardiovascular surgical procedure without CC/MCC 254 other vascular procedure without CC Complex 237 major cardiovascular surgical procedure with MCC 252 other vascular surgical procedure with MCC 253 other vascular surgical procedure with CC

9 Methods Cost Analysis Comparison of hospitalization costs between standard and complex groups Lost billing opportunity for miscoded patients = (covered charges for corrected DRG) (covered charges for originally coded incorrect DRG) Total reimbursement loss = (total cost of hospitalization) (total reimbursement for originally coded DRG)

Results: Inpatient Outcomes Outcome Standard: Complex: P-value Corrected MS-DRG 238 % (n=90) Corrected MS-DRG 237 % (n=14) LOS 3.0+/-1.5 days 7.6 +/-5.8 days P < 0.0001 ICU LOS 0.4 +/-0.7 days 2.

10 Results: Inpatient Outcomes Outcome Standard: Complex: P-value Corrected MS-DRG 238 % (n=90) Corrected MS-DRG 237 % (n=14) LOS 3.0+/-1.5 days 7.6 +/-5.8 days P < ICU LOS 0.4 +/-0.7 days 2.4 +/-3.1 days P < Intraop complication 27.8% (25) 35.7% (5) P = Inpatient complication 15.6% (14) 71.4% (10) P < Pulmonary 2.2% (2) 28.6%(4) P < Cardiac 4.4%(4) 21.4%(3) P= Surgical Site 0% (0) 7.14% (1) P=0.011 GI 1.1%(1) 21.4%(3) P< Inpatient mortality 0 0 n/a

11 Results: Costs & Reimbursement $40,445 $28,863 $30,166 $20,815

Results: Lost Billing Opportunities Coding event N Lost billing opportunity (per patient) Lost billing opportunity (total) Reimbursement loss (mean loss per patient) Total reimbursement loss 237

12 Results: Lost Billing Opportunities Coding event N Lost billing opportunity (per patient) Lost billing opportunity (total) Reimbursement loss (mean loss per patient) Total reimbursement loss 237 miscoded as 4 $58, $234, $18, $72, miscoded as 6 $55, $330, $14, $88, miscoded as 1 $81, $81, $16, $16, correctly coded 9 n/a n/a $8, $80, correctly coded 84 n/a n/a $7, $636, TOTAL 104 $646, $8, $894,287.00

13 Causes of MS-DRG Miscoding Provider Documentation Hospital Ownership Hospital Size Teaching Status Location Health Service Area (HSA) Inter-coder variability

14 Potential Solutions Educational Seminars Monthly coding seminars found to increase residents coding compliance [13]. Covering MS-DRGs and coding accuracy practices improves documentation [8] ICD-10 Coding System Increased breadth and granularity Provider Queries Coder queries directly to physicians to clarify unclear documentation via EMR

15 Conclusions Miscoding is a potential issue for hospital reimbursement in vascular surgery Our study demonstrates a large lost billing opportunity with undercoding and miscoding of EVARs from Future directions: Further reviews of coding practices Developing potential interventions

References 1. Fillinger M. Total Number of AAA Repairs in US Declining Annually Since 2005. Society for Vascular Surgery Vascular Annual Meeting, Plenary Session 4: S4 2016; Baltimore, MD. 2. Stone DH, Horvath AJ, Goodney PP, et al.

16 References 1. Fillinger M. Total Number of AAA Repairs in US Declining Annually Since Society for Vascular Surgery Vascular Annual Meeting, Plenary Session 4: S4 2016; Baltimore, MD. 2. Stone DH, Horvath AJ, Goodney PP, et al. The financial implications of endovascular aneurysm repair in the cost containment era. J Vasc Surg. Feb 2014;59(2): , 290.e Staff HI. An Inpatient Prospective Payment System Overview: Diagnosis Related Groups. CCS Prep! 2006;16(5):6. 4. Network, Medicare Learning. Acute Care Hospital Inpatient Prospective Payment System: Payment System Series. Washington, DC: Department of Health & Human Services - Centers for Medicare & Medicaid Services; February Mills RE, Butler RR, Averill RF, McCullough EC, Fuller RL, Bao MZ. Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments. Journal of AHIMA website Staff HI. An Inpatient Prospective Payment System Overview: Diagnosis Related Groups. CCS Prep! 2006;16(5):6. 7. Network, Medicare Learning. Acute Care Hospital Inpatient Prospective Payment System: Payment System Series. Washington, DC: Department of Health & Human Services - Centers for Medicare & Medicaid Services; February Rosenbaum BP, Lorenz RR, Luther RB, Knowles-Ward L, Kelly DL, Weil RJ. Improving and measuring inpatient documentation of medical care within the MS-DRG system: education, monitoring, and normalized case mix index. Perspect Health Inf Manag. 2014;11:1c.

References 9. Chescheir N, Meints L. Prospective study of coding practices for cesarean deliveries. Obstet Gynecol. Aug 2009;114(2 Pt 1):217-223. 10. Silverman E, Skinner J.

17 References 9. Chescheir N, Meints L. Prospective study of coding practices for cesarean deliveries. Obstet Gynecol. Aug 2009;114(2 Pt 1): Silverman E, Skinner J. Medicare upcoding and hospital ownership. J Health Econ. Mar 2004;23(2): Rangachari P. Coding for quality measurement: the relationship between hospital structural characteristics and coding accuracy from the perspective of quality measurement. Perspect Health Inf Manag. Apr 2007;4: Chescheir N, Meints L. Prospective study of coding practices for cesarean deliveries. Obstet Gynecol. Aug 2009;114(2 Pt 1): Jones K, Lebron RA, Mangram A, Dunn E. Practice management education during surgical residency. Am J Surg. Dec 2008;196(6): ; discussion Coomer NM, McCall NT. Examination of the accuracy of coding hospital-acquired pressure ulcer stages. Medicare Medicaid Res Rev. 2013;3(4). 15. Saucedo J, Marecek GS, Lee J, Huminiak L, Stulberg SD, Puri L. How accurately are we coding readmission diagnoses after total joint arthroplasty? J Arthroplasty. Aug 2013;28(7):

Frightening Scenario or Manageable Change? Determining the Realistic Reimbursement Impact of ICD-10 on MS-DRGs. Lori Jayne, RHIA Donna Smith, RHIA

Frightening Scenario or Manageable Change? Determining the Realistic Reimbursement Impact of ICD-10 on MS-DRGs Lori Jayne, RHIA Donna Smith, RHIA Objectives Speaker introductions Processes to determine