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1 HomeTown Health HCCS Hospital Consortium Project: Track 3- Clinical Documentation: Strategies for Sharpening Focus Jenan Custer RHIT, CCS, CPC, CDIP AHIMA Approved ICD-10-CM/PCS Trainer Director of Coding Healthcare Coding and Consulting Services (HCCS) Melissa Edenburn MS, RHIA, CCS AHIMA Approved ICD-10-CM/PCS Trainer Senior Inpatient Auditor and Trainer Healthcare Coding and Consulting Services (HCCS) 1 Disclosure of Proprietary Interest HCCS does not have any proprietary interest in any product, instrument, device, service, or material discussed during this learning event. The education offered by ICAHN in this program is compensated by the HRSA Small Hospital Improvement Program (SHIP) grant, Iowa FY17-18, Contract #5888SH01. 2 L earning Outcomes By the end of this session, attendees should be able to: Identify how are DRG s assigned? Recognize Principle Diagnosis and the Impacts Identify Complications and Comorbidities (CC s) and (MCC s) Major CC s Identify Procedure documentation/coding and impacts Quality Impacts: HACS, Complication, etc. Learning Outcome Standard: This program is based on compliance guidelines set forth by entities like, but not limited to: AHIMA, ACDIS, CMS, The Joint Commission, and Local FI/MACS. 3 1

2 MS-DRG Assignment MS-DRGs put into action in 2007; Currently using MS Grouper /1/2016-9/30/ MS-DRG classifications 25 MDCs MDC- Major Diagnostic Category Group based on principal diagnosis 2 sections- Medical and Surgical Patients are grouped that demonstrate similar consumption of hospital resources and LOS patterns Mandated for all IPPS Medicare hospitals MS-DRG Assignment DRGs function to determine hospital reimbursement Quality of care Evaluating utilization of services CMS assigns a yearly hospital base rate Based on past years case mix data MS DRG reimbursement is then determined by: Relative weight x hospital base rate= Hospital Payment MS-DRG Assignment MS DRG assignment is based on: Principal and secondary diagnosis and procedure codes Sex of the patient Discharge status Presence or absence of CCs and/or presence or absence of MCC s Birthweight for neonates 2

3 Complications and Comorbidities Complications and Comorbidities vs Major C & C s Complication-condition that arises during the hospital stay that prolongs the length of stay Comorbidity-pre-existing condition that affects the treatment received and/or prolongs the length of stay. CC-a significant acute disease/manifestation o a chronic disease/end stage chronic disease or chronic disease associated with systemic physiological decompensation and debility that have consistently greater impact on hospital resources MCC meets same criteria as a CC but is associated with higher acuity level and hospital resource consumption is expected to be higher than that for a CC condition Hierarchy of DRG s based on CC/MCC code assignment MS-DRG Assignment Hierarchy of DRGs based on CC/MCC code assignment Lower (lesser number) DRG has higher reimbursement Backwards hierarchy MS-DRG 539, Osteomyelitis with MCC MS-DRG 540, Osteomyelitis with CC MS-DRG 541, Osteomyelitis without CC/MCC MS-DRG Assignment Two types of MS DRG s- Medical and Surgical Each MDC falls into either a surgical or non surgical group Surgical DRG s are dependent on the TYPE of procedure performed Patients were initially considered surgical if they had a procedure performed which would require the use of the operating room. However, since patient data does not usually indicate whether a patient was taken to the operating room, surgical patients were identified based on the procedures which were performed. Pre-MDC MS-DRG s- are grouped by surgical procedure rather than principal diagnosis. Includes: Bone marrow/organ transplant cases Tracheostomy cases 3

4 MS- DRG Assignment Physicians Role Proper MS-DRG assignment requires a complete and thorough accounting of the following: Principal Diagnosis Procedures Complications Comorbidities (ALL relevant pre-existing conditions) Signs and symptoms when diagnoses are not established Discharge status 2017 DRG Expert OPTUM 360 MS- DRG Assignment Physicians Role Because MS-DRG assignment is based on documentation, the record must: Be comprehensive and complete Include all diagnoses, procedures, complications and comorbidities, as well as abnormal test results and suspected conditions-including what was done to investigate/evaluate them Be timely Be legible Physicians must be actively involved in the query processrespond timely, document responses as required by policy 2017 DRG Expert OPTUM 360 Test your Knowledge 1) MS-DRG assignment is typically based on? 2) The three types of MS-DRG assignments are: a. MS DRG, MDC, Medical b. MS DRG, Surgical, HAC c. Surgical, Medical and Pre-MDC 4

5 Steps to determine MS- DRG Assignment Version 34 available from CMS online, can be used to assist Steps to determine MS DRG Assignment 1) Did patient have an OR procedure? Y= refer to alpha or numeric index to locate all potential MS DRG assignments N= Look up diagnosis by alpha or numeric diagnosis index Steps to determine MS DRG Assignment 1. Find your code 2. Look at DRG titles 3. Determine DRG based on CC/MCC codes as secondary diagnoses 4. J41.0 Chronic Bronchitis with no CC/MCC condition would map to DRG 203 5

6 Steps to determine MS DRG Assignment Procedure Example Patient with Acute appendicitis and a Laparoscopic appendectomy 1) Procedure code- 0DTJ4ZZ Using the CMS website-choose MDC 06 Diseases & Disorders of the digestive system, scroll down to Appendectomy-6 possible DRGs Appendectomy Steps to determine MS DRG Assignment P rocedure E xample Click on Appendectomy Hyperlink You will see full title of the DRGs DRG 338 APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC DRG 339 APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC DRG 340 APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC DRG 341 APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC DRG 342 APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC DRG 343 APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC HAC s- Hospital Acquired Conditions Deficit Reduction Act 2005-Quality adjustment for certain HAC s-no $ if condition was caused/inadvertently caused by hospital Definition of HAC Is either high cost, high volume, or both Results in the assignment of a case to a MS-DRG that has a higher payment when present as a secondary diagnosis (cc / mcc) Could have been reasonably prevented through the application of evidence-based guidelines 6

7 14 categories (not codes) of HACs- cms.gov (Excel document downloads of individual diagnosis and procedure codes) Air Embolism Blood Incompatibility Catheter-Associated UTI DVT and PE Following: Total Knee Replacement, Hip Replacement Falls and Trauma: Fractures, Dislocations, Intracranial Injuries, Crushing Injuries, Burns, Other Injuries Foreign Object Retained After Surgery Iatrogenic Pneumothorax with Venous Catheterization Manifestations of Poor Glycemic Control Surgical Site Infection (SSI) Following Bariatric Surgery for Obesity SSI Following Certain Orthopedic Procedures: Spine, Neck, Shoulder, Elbow SSI-Mediastinitis after CABG Stage III & IV Pressure Ulcers Surgical Site Infection Following Cardiac Implantable Electronic Device Vascular Catheter-Associated Infection (includes site) Present on Admission designation Codes listed on the HAC codes list are only considered hospital acquired if they were NOT present on admission Example: Patient was admitted with Stage 1 (L89151) sacral pressure ulcer that progressed during his admission to a Stage 3 (L89153). Coding guidelines require both stages of ulcer to be coded, however stage 1 would be noted as present on admission. The stage 3 which is a MCC condition would be noted as NOT present on admission and your facility would not receive the benefit of a MCC condition when determining DRG assignment. Hospital Never Events: Adverse events in health care are one of the leading causes of death and injury in the United States today. The National Quality Forum s 2011 list of 29 events is not intended to capture all of the adverse events that could possibly occur in hospital facilities. 29 events are grouped into 7 categories: surgical, product or device, patient protection, care management, environmental, radiologic, and criminal 7

8 Most commonly reported Never Events Wrong-site surgery Suicide Op/Post-op complication Delay in treatment Medication error Patient fall Medicare covers services related to HACs, facility receives only a portion of typical reimbursement Medicare will not cover any aspect of services related to the three wrong site surgery never events specified in the NDC s Wrong surgical or other invasive procedure performed on a patient. Surgical or other invasive procedure performed on the wrong body part. Surgical or other invasive procedure performed on the wrong patient. A never event prevents all payments to the hospital and physicians involved in the procedure Working Example #1 Assign the correct MS DRG using CMS website Case Scenario: 87 year old male admitted with MRSA Pneumonia, intubated and placed on mechanical ventilation in the ED. He was extubated after 6 days and expired. Step 1-Choose MDC-What Body System? MDC 04 Respiratory System Step 2-Medical or Surgical DRG? *Surgical DRG for O.R. Procedures 8

9 Working Example #1 Working Example #1 Working Example #2 Acute Cholecystitis with post-op Respiratory failure, left on mechanical vent 134 hours. Principal diagnosis? Acute chole vs. resp failure? MDC 07- Hepatobiliary system K81.0 Acute cholecystitis J Acute and chronic postprocedural respiratory failure Procedure codes- 5A1955Z- Respiratory ventilation 0FT44ZZ- Resection of gallbladder 9

10 Working Example #2 Closing thoughts Your facility's accuracy of ICD-10 CM and PCS code assignment will directly influence the overall DRG assignment Documentation must be complete Principle diagnosis, CC/MCC conditions and procedure codes must be correctly assigned Query responses must be timely HACs and/or Complications should be documented despite adverse reimbursement Learning Outcomes Now that this session is complete, attendees should be able to: Identify how are DRG s assigned? Recognize Principle Diagnosis and the Impacts Identify Complications and Comorbidities (CC s) and (MCC s) Major CC s Identify Procedure documentation/coding and impacts Quality Impacts: HACS, Complication, etc

11 Value Quality THANK YOU FOR YOUR TIME WE WELCOME ALL QUESTIONS