MS-DRG 180-181-182 slides

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Respiratory Respiratory NeoplasmNeoplasm

Charmira Orr BS,LPN,CCS,CPC,CCDSDirector of Coding and Appeals

Intersect Healthcare, Inc.

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Participants will review and understand

Learning Objectives

Participants will review and understand the RAC’s focus

Participants will review and understand how to incorporate guidelines to aid in p gauditing practices

22010 Intersect Healthcare, Inc.

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The RAC’s Focus

2010 Intersect Healthcare, Inc. 3

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DiagnosticDiagnostic

InformationInformation

ProceduresProceduresDischargeDischarge

DiagnosisDiagnosis

DischargeDischarge


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MS‐DRG 180,181,182

Issue Details Name Respiratory 175, 176, 180, 181, 182, 183, 184, 185, 186, 187, 188, 192, 196, 197, 198, 199, 200, 201, 202, 203, 204, 205, 206 (Medical Necessity Excluded) Number B001232010 Description MS-DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded on the hospital claim, matches both the attending physician description and the information contained in the medical record. Reviewers will validate MS-DRGs 175, 176, 180, 181, 182, 183, 184, 185, 186, 187, 188, 192, 196, 197, 198, 199, 200, 201, 202, 203, 204, 205 and 206 for diagnoses and procedures affecting the MS-DRG assignment. Claim Type Inpatient Issue Type Complex Overpayment / Underpayment Overpayment and Underpayment Dates of Service 10/1/2007 - Open States IL, IN, KY, MI, MN, OH WI Policy Related Links ICD 9 CM Coding Manual (for dates of service on claim)OH, WI Policy Related Links ICD-9-CM Coding Manual (for dates of service on claim)

ICD-9-CM Addendums and coding clinicsPIM Ch 6.5.3, Section A – C - DRG Validation Review

Present on Admission Indicator Systems ImplementationOIG - Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99)

Date Approved 6/10/2010

CGI Federal , 2010 ©


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Things We Know

i h CC/ CC G OS 3 0 0 81 9Without CC/MCC

With CC

With MCC

• GMLOS 3.0, RW 0.8159

• GMLOS 4.3, RW 1.2062

• GMLOS 5.9, RW 1.7263

Principle Diagnosis • Malignant, Secondary, Benign, In situ, Lipoma’s


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Principle Diagnosis

• The condition found after study to have occasioned the current admission or encounter

• The majority of treatment can often be used as a guide to selecting the principal diagnosisselecting the principal diagnosis

• Primary and Secondary Sites


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PRIMARY VS. SECONDARY SEQUENCING GUIDELINESSEQUENCING GUIDELINES


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PRIMARY

When treatment is directed toward the primary site, the malignancy of that site is designated as the principal diagnosis unless the encounter or hospital admission is solely for the purpose of radiotherapy, chemotherapy, or immunotherapypy, py, py

– Then the primary malignancy is a secondary diagnosis, Encounter ( V-Codes ) First

– If two primary sites are present, each is coded p y p ,as a primary neoplasm


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Follow the Treatment

If there are 2 primary sites, however, treatment is directed primarily toward one site, that site should be designated as the principal diagnosis

If treatment is directed equally toward both sites, either may be designated as the principal diagnosis

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Secondary SitesIf treatment is directed only at the secondary site, the secondary site is designated as the principal diagnosis– An additional code is assigned for the primary malignancymalignancy

– A V ‐ code is assigned as the additional code if the primary site has resolved


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Presumed Secondary Neoplasm

di iMediastinumMeningesPeritoneumPleuraRetroperitoneumSpinal CordSites Classifiable to 195BoneBrainDiaphragmDiaphragmHeartLiverLymph nodes


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Secondary DiagnosisDiagnoses that coexist at the time of admission or

develop subsequently or affect patient care for the current develop subsequently or affect patient care for the current hospital episode.

Should only be documented when?Clinically Evaluated

Diagnostically Tested

Increase nursing care or monitoring

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Therapeutically TreatedIncreased LOS

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Common CC/MCC Conditions

h / i i i• Asthma w/acute exacerbation or status asthmaticus

• Bronchitis w/ acute exacerbation

• CKD

• Aspiration pneumonia• Empyema• Pneumonia• Pulmonary embolism• Lung Abscess

• CKD• Respiratory insufficiency• Pulmonary edema• Pneumothorax• Tracheostomy

li ti

• Spontaneous tension pneumothorax

• Mediastinitis• Bacterial pleural effusion• Acute Respiratory Failure

complicationsp y

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Common Diagnostic Procedures

• CXR• CT scans• PET scans• Sputum Cytology• Sputum Cytology• Biopsies• Bronchoscopy• Mediastinoscopypy• Bone scans


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Common Treatmentsdi h h Ch h• Radiotherapy, Immunotherapy, or Chemotherapy

• When a patient encounter is solely for the administration of chemotherapy, immunotherapy, or radiation therapy, assign the appropriate code as the first-listed or principal diagnosis - ( V –Codes)

• If the encounter is to receive one or more of these • If the encounter is to receive one or more of these therapies, each pertinent code should be assigned, in any sequence

• Additional code should be assigned for the malignancy• Procedure codes should also be assigned

92 2x Radiation therapy– 92.2x Radiation therapy– 99.28 Immunotherapy– 99.25 Chemotherapy


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Documentation Highlights

• Acute vs. chronic• Diagnostic test –documented diagnosis• Diagnostic reports- document diagnosis in

progress notesI iti t d t t t l• Initiated treatment or plans

• Severity of condition• Etiology of condition


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Auditing for Neoplasm


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Worksheet

h fLength of stay:

Discharge status:

Home or Self Care ‐01

Discharged/ Transferred to a Short Term General Hospital for Inpatient Care ‐02

Discharged/ Transferred to a SNF with Medicare Certification in Anticipation of killed Care ‐ 03

Discharged/Transferred to an Intermediate Care Facility ‐ 04

Discharged/Transferred to Another Type of Health Care Facility Not elsewhere in the Code List‐ 05

Discharged/ Transferred to Home Care‐ 06

AMA ‐07

Expired‐20


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Worksheetd i i O dAdmission Orders:

Malignant condition noted

Was treatment during stay directed at this area: Yes or No

Was patient admitted for treatment only? Yes or No

Were there any complications noted during stay? Yes or No If so, please listlist__________________________________________________________________________

Were any procedures performed on either the primary or secondary malignancy? Drop Down Box Yes or No If so; please list ‐‐‐‐‐‐‐‐‐‐ Then area to fill in the blank_____________________________________________________________________________

Is there any mention in the medical record that a primary malignancy has beenIs there any mention in the medical record that a primary malignancy has been excised or eradicated? Box Yes or No if so; is there any treatment directed at this area? Yes or No


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Worksheeth i li ill b i di d h d iIs the primary malignancy still present, but treatment is directed at the secondary site only during the admission?

Secondary diagnosis: _____________________________________________________________________

Were these diagnoses treated during pt. stay? Yes or No if so; list Fill in the blank treatments____________________________________________________________________


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Appealing a Appealing a Respiratory Respiratory Neoplasms Neoplasms

Inpatient DenialInpatient Denial

‘Yomi Faparusi, MD JD PhDDirector, Medical Review and Research,

Intersect Healthcare, Inc.

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Understand how to create a successful

Learning Objectives

Understand how to create a successful coding or medical necessity appeal for Respiratory Neoplasms denials by:

Understanding the Issue at HandProviding a Road Map for the ReviewerPresenting a Preponderance of Best Evidence

Understand how to tailor appeals to the Administrative Law Judge


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Top target MS DRG during RAC demonstration

Understanding the Issue at Hand

Top target MS DRG during RAC demonstration project

Historically have been identified as problematic DRGsNational Validation Study: HHS-OIG recommended review of admissionsSh t h it li ti ith l ti l hi h Short hospitalization with relatively high unnecessary admission rates

PEPPER data (FY 2007)Error rate of 11%DRG changes: 5% ; Admission denials: 6%


Key Learning: Respiratory Neoplasms expected to maintain status with the permanent RAC program especially with Medical Necessity audits.

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Usually an “outlier” inpatient case

Understanding the Issue at Hand

Usually an outlier inpatient caseRarely need inpatient admissionsShort hospitalizationAdmitted when patient presents with complications and/or for management of co morbidities

BleedingObstructiveHormonal (ectopic production) etc.

Occupational and Social issuesSmokingCoal miningAsbestos e pos eAsbestos exposure


Key Learning: Most patients with respiratory neoplasms are treated as outpatient hence look for documentation why index case is inpatient

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The Appeal AlgorithmNCDNCD

LCD

COMMUNITY STANDARDS OF MEDICAL CARE


LIMITATION OF LIABILITY

RULE

TREATING OR ATTENDING

PHYSICIAN RULE

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NCD

NCDs & LCDsNCDEnsure effective on the date of service (may have been retired)

Aprepitant for Chemotherapy-Induced Emesis (110.18)Certain Drugs Distributed by the National Cancer Institute (110.2)Erythropoesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions (110.21)p ( )

LCDCheck with your FI etc.


Key Learning: The ALJ is bound by the NCDs however mayconsider the LCDs at his/her discretion

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Providing a Road Map

J tifi ti f M di l N itJustification of Medical NecessityThe arguments presented below justify the medical necessity of hospital services. Just as importantly, the arguments justify that

the hospital services provided are “generally accepted by the professional community as being safe and effective treatment.”

Signs and Where Skilled Outcome of Source of Symptoms or Complications

Documented Intervention(s) Intervention Recommendation

Drowsiness, Confusion, Seizures

*Hyponatremia

Physician’s admission notes dated 3/10/2010; entered electronically by Dr. Glenn;

Intubated; I.V. hypertonic saline at 125mL/h for 3 hours

Mental status changes reversed and patient no longer had seizures

Dr. Miller (see Nephrology Consult notes dated 3/10/2010; page 32 (of 175) of the Medical Record


Page 27 (of 175) of the Medical Record

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ACCP EVIDENCE-BASED GUIDELINES

Preponderance of Evidence

ACCP EVIDENCE-BASED GUIDELINESAmerican College of Chest Physicians

Health and Science Policy Committee

Diagnosis and management of lung cancer

Reviewed annually for new developments Most current ACCP guidelines for lung cancer were published in the September 2007 supplement edition of CHEST

American College of Chest Physicians. (2007). Diagnosis and Management of Lung Cancer: ACCP Guidelines.

CHEST: 132 (3suppl.) http://chestjournal.chestpubs.org/content/132/3_suppl


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• ACCP PUBLICATIONS • HOME • CURRENT ISSUE • ARCHIVE

FEEDBACK• FEEDBACK • SUBSCRIBE • ALERTS • HELP

Table of Contents

September 1 2007; 132 (3 suppl)


September 1, 2007; 132 (3 suppl)Diagnosis and Management of Lung Cancer: ACCP Guidelines

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American Society of Clinical Oncology


American Society of Clinical Oncology (ASCO)

Non small cell lung cancer (NSCLC) guidelinesAmerican Society for Clinical Oncology (ASCO). (2009). Clinical Practice Guideline, Lung Cancer. http://www.asco.org/ASCOv2/Practice+%26+Guidelines/p gGuidelines/Clinical+Practice+Guidelines/Lung+Cancer

Other professional associationsAs applicable to the management of complications or co morbidities


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Use the guidelines that were available and in effect at the

Parting Thoughts

Use the guidelines that were available and in effect at the time the services were provided, coded, and billed!

Provide clear and accurate reference information, including URLs.

Include all supporting guidelines in full text documents pp g g(the pertinent pages) as attachments to your appeal.


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Best Practice for Appeal

Summary

Best Practice for AppealDetermine if documentation in the chart supports an appealSupport the coding decision with:

ICD‐9‐CM Coding Guidelines

ICD‐9‐CM Official Guidelines for Coding and Reporting IC 9 CM Official Guidelines for Coding and Reporting

American Hospital Association's (AHA) Coding Clinic for ICD‐9‐CM

Support the physician’s decision making process with evidence based guidelinesUse CMS’s coverage policies and guidelines


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THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM:

Resources

An Evaluation of the 3-Year Demonstration, June 2008https://www.cms.gov/RAC/Downloads/RACEvaluationReport.pdf

Official ICD-9-CM Guidelines for Coding and ReportingEffective October 1, 2009http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm

American College of Chest Physicians. (2007). Diagnosis and Management of Lung Cancer: ACCP Guidelines. CHEST: 132 (3suppl.) http://chestjournal.chestpubs.org/content/132/3_suppl

American Society for Clinical Oncology (ASCO). (2009). Clinical Practice Guideline, Lung Cancer. htt // /ASCO 2/P ti +%26+G id li /G id li /Cli ihttp://www.asco.org/ASCOv2/Practice+%26+Guidelines/Guidelines/Clinical+Practice+Guidelines/Lung+Cancer


MS-DRG 180-181-182 slides

Health & Medicine

Transcript of MS-DRG 180-181-182 slides