MS-DRG 207 slides

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Part Three:

Top MSTop MS--DRG’s at RiskDRG’s at RiskDocumentation, Coding Audit, and Appeal Workshops

Sponsored by Intersect Healthcare, Inc.

Part Three: Respiratory Failure with Ventilator

Support >96 hours(MS-DRG 207)

Next Session:W d d J l 7Wednesday, July 7

1:00PM ESTChest Pain (1 day stay):

A Clinical Documentation, Coding Audit & Appeal Workshop (MS-DRG 313)

Part Three:

Top MSTop MS--DRG’s at RiskDRG’s at Risk

Sponsored by Intersect Healthcare, Inc.

Documentation, Coding Audit, and Appeal Workshops

Part Three: Respiratory Failure with Ventilator

Support >96 hours(MS-DRG 207)

Your Panel:

Tracey Goessel, MDClinical Overview of MS-DRG 207

Charmira Johnson, CCS, BS, LPN, CCDSThe RAC and MS-DRG 207

Denise Wilson, RN, RRT, MSAppealing a MS-DRG 207 Denial

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MS DRG 207: Respiratory Failure with

V til t S t >96 h

Tracey Goessel, M.D.

Ventilator Support >96 hours

Tracey Goessel, M.D.CEO

FairCode Associates

Inability of the lungs to perform their basic

What is “Respiratory Failure”?

y g ptask of gas exchange: the transfer of oxygen from inhaled air into the blood and the transfer of carbon dioxide from the blood into exhaled air.

We tend to think of it as being a state We tend to think of it as being a state where the patient’s oxygen is too low; but it can be also a state where the CO2 is too high.

42010 Intersect Healthcare, Inc. FairCode

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Alveolar Hypoventilation– Drug overdose/respiratory suppressants– Chest wall trauma

What are the Causes of Respiratory Failure?

Chest wall trauma– Neurologic disorders (stroke, MS), Neuromuscular disorders

(myasthenia gravis), Muscular disorders (muscular dystrophy)

Capillary wall/alveolar damage– Near drowning– Pesticide exposure– Smoke inhalation/fire

Inadequate alveolar wall surface – COPD!Loss of elasticity in the lungs

– Pulmonary fibrosis– Sarcoidosis– ~ 100 others

Loss of pulmonary vascular bed– Massive pulmonary embolism


How Do We Diagnose Respiratory Failure – From a Clinical and Coding Standpoint?

In patients without underlying disease, the general rule of thumb is pO2 < 60 g pand/or the pCO2 > 50. COPD patients often have baseline pO2s that are low and pCO2s that are elevated.

Look at pH: is patient acidotic, or compensated?Drop of 10-15 points in pO2 from baseline is p p psuggestive.

Patient does not need to be on ventilator for respiratory failure to be the diagnosis!


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The use of the term “respiratory insufficiency” as a

What are the Challenges in Physician Documentation of Respiratory Failure?

The use of the term “respiratory insufficiency” as a synonym.

The failure to document baseline blood gases in COPD patients

The hesitancy to document respiratory failure if the patient is not on a ventilator.


BiPAP S/T-D ventilatory support system: augments patient’s ability to breath on their own – while it is continuous it does not qualify as “continuous

When is ventilatory support considered Non-invasive mechanical ventilation?

continuous, it does not qualify as continuous manual ventilation” because it is not given via ET/NT or trach tube

CPAP - continuous positive airway pressure not through ET/NT or trach tube

NIPPV i i iti til tiNIPPV - noninvasive positive pressure ventilation

NPPV - nonpositive pressure ventilation

PEEP - not given via ET/NT or trach tube


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BiPAP S/T-D ventilatory support system: augments patient’s ability to breath on their own – while it is continuous it does not qualify as “continuous

When is ventilatory support considered Non-invasive mechanical ventilation?

continuous, it does not qualify as continuous manual ventilation” because it is not given via ET/NT or trach tube

CPAP - continuous positive airway pressure not through ET/NT or trach tube

NIPPV i i iti til tiNIPPV - noninvasive positive pressure ventilation

NPPV - nonpositive pressure ventilation

PEEP - not given via ET/NT or trach tube


BiPAP though given via ET/NT or trach tube

When is Ventilatory Support Considered Invasive Mechanical Ventilation?

BiPAP though given via ET/NT or trach tube

CPAP given via ET/NT or trach tube (mostly!)

PEEP given via ET/NT or trach tube

IPPV - invasive positive pressure ventilationp p


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Capturing when the post-operative period on a ventilator counts as an “unexpected, extended period of mechanical ventilation ”

What are the Challenges in Physician Documentation of a Patient

Already on a Ventilator?

period of mechanical ventilation.

Capturing the time of intubation.Anesthesia records usually precise; ER records less so.Incision of tracheotomy/cricothyroidostomy represents moment of intubation in surgical airways.

Capturing the time of extubationCapturing the time of extubation.Oral/nasotracheal intubation: ends when tube pulled.Weaning periods count with trach patients.Tube may remain indefinitely, so once pt weaned off mechanical ventilation, that is when clock stops.Respiratory therapy notes generally more helpful and specific than MD notes


Respiratory failure is not a symptom. It is a diagnosis. As such, it may be coded as the principal diagnosis even when the cause is known

What are the Challenges in Determining When to Make Respiratory Failure Principal Diagnosis?

diagnosis, even when the cause is known.

For the most part, if respiratory failure is present at admission, it trumps the underlying cause. You list it first.

Chapter-specific coding guidelines may over-ride thi lthis rule:– Obstetrics – Poisoning– HIV– Newborns


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A 24-year-old female throws a massive pulmonary embolus, requires intubation,

Example:

and is on the ventilator for 5 days.– If the embolus is a peri-partum pulmonary embolism,

then OB sequencing guidelines require you to list PE first. This leads you to 781/782 Other AntepartumDiagnoses with or without Medical Complications

– If the embolus is not obstetric in nature, then respiratory failure may be sequenced first, leading to MS DRG 207.


Work to get the attending to specify the cause of the respiratory failure. If he/she

Accordingly:

documents that it is a cause outside of the poisoning/HIV/newborn/obstetric arena, you may code respiratory failure first.


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When in Doubt…

Refer to Coding Clinics

Query, query, query!


Respiratory Insufficiency– The term “respiratory insufficiency” is not specific from a coding

standpoint. The patient presented with pneumonia, cyanosis and the following blood gases: pH 7.29/pO2 57/pCO2 49/HCO3 15. Please define the condition that was the underlying cause of the above documented

Sample Queries

the condition that was the underlying cause of the above documented laboratory studies.

Unexpected, extended period of ventilation– The patient underwent an anterior/posterior cervical fusion. Post-

operatively, you noted “extensive anterior edema” and maintained the patient on a ventilator for 18 hours in the ICU. In your opinion, does this represent a normal post-operative ventilatory duration, an extended post-operative ventilatory duration, or are you unable to determine?

Underlying cause of respiratory failure– This patient presented with respiratory failure requiring mechanical

ventilation. He was documented to have consumed an overdose of Tylenol, requiring Mucomyst administration, as well as bi-lobar aspiration pneumonia. Please define what, in your opinion, was the underlying cause of the respiratory failure, if known.

Copyright 2009 5 162010 Intersect Healthcare, Inc. FairCode

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The RAC and

MS-DRG 207MS DRG 207

Charmira Orr BS, LPN, CCS, CPC, CCDSC a a O S, , CCS, C C, CC S

Intersect Healthcare, Inc.

Learning Objectives

T U d t d H t U P t Fi di To Understand How to Use Past Findings of the RAC Demonstration Area to Help Tell Your Coding Validation Story

To Understand How to Break Down the Guidelines to Abstract Data from the Medical RecordMedical Record

To Understand How to Tell Your Coding Validation Story

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The RAC Demonstration

Wrong Principal Diagnosis-RACs found that the Wrong Principal Diagnosis RACs found that the principal diagnoses on claims did not match the principal diagnoses in the medical record. For example, respiratory failure (code 518.81) was listed as the principal diagnosis, but the medical record indicated other conditions such as sepsis (code 038.0–038.9) was the principal diagnosis.

In 2007 42% of the recoupment s were directly tt ib t d t i t diattributed to incorrect coding

In NY $ 9.5 Million collected, CA $ 4.1 million collected, FL $1.7 Million collected.


Connolly Healthcare ©2010

Issue Name: Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207 (At this time, Medical Necessity excluded from review).

Description: DRG Validation requires that diagnostic and procedural information and the DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS DRG 207, previously DRG 565, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.

Provider Type Affected: Inpatient Hospital

Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia (WPS only), West Virginia (WPS only) Additional Information: Additional information can be found on the following manuals/publications:

ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H ICD-9-CM Addendums and Coding Clinics PIM Ch. 6.5.3, Section A-C DRG Validation Review


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Respiratory System Diagnosis with Ventilator Support >96 Hours (MS-DRG 207)

MDC4 GMLOS/RW AND

•Medical‐Any Principal Diagnosis in MDC 4

• GMLOS‐12.8

• RW 5.1055 • Transfer DRG

• Non Operating Room Procedures

• ICD‐9 CM 96.72‐Continuous invasive mechanicalin MDC 4 DRG mechanical ventilation for 96 consecutive hours or more


Understanding the Guidelines

The Uniform Hospital Discharge Data Set ( UHDDS) defines the principal diagnosis as the condition defines the principal diagnosis as the condition established after study and is the primary reason responsible for the admission of the patient to the acute care setting within the hospital. In accordance to coding guidelines the reason and circumstances that led to the inpatient admission must take precedence as the primary diagnosis.

- ICD- 9 codes Various respiratory Conditions throughout the Index

AND

Mechanical Ventilation- Located under ICD-9 code 96.7Includes: BiPAP delivered through endotracheal tube or tracheostomy (invasive interface)

CPAP delivered through endotracheal tube or tracheostomy (invasive interface)Endotracheal respiratory assistance, Invasive positive pressure ventilation [IPPV]Mechanical ventilation through invasive interface That by tracheostomyWeaning of an intubated (endotracheal tube) patient

Excludes: Noninvasive ventilation like face mask, nasal cannulas, nasal catheters


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Mechanical Ventilation –ICD-9 96.7 Guidelines Cont’d

Endotracheal IntubationTo calculate the number of hours (duration) of continuous mechanical ventilation during ahospitalization, begin the count from the start of the (endotracheal) intubation. Theduration ends with (endotracheal) extubationduration ends with (endotracheal) extubation.

If a patient is intubated prior to admission, begin counting the duration from the time ofthe admission. If a patient is transferred (discharged) while intubated, the duration wouldend at the time of transfer (discharge).

For patients who begin on (endotracheal) intubation and subsequently have atracheostomy performed for mechanical ventilation, the duration begins with the(endotracheal) intubation and ends when the mechanical ventilation is turned off (afterthe weaning period).

TracheostomyTo calculate the number of hours of continuous mechanical ventilation during ahospitalization, begin counting the duration when mechanical ventilation is started. Theduration ends when the mechanical ventilator is turned off (after the weaning period).If a patient has received a tracheostomy prior to admission and is on mechanicalventilation at the time of admission, begin counting the duration from the time ofadmission. If a patient is transferred (discharged) while still on mechanical ventilation viatracheostomy, the duration would end at the time of the transfer (discharge).

Please Note Must code in addition If performed:endotracheal tube insertion (96.04)tracheostomy (31.1-31.29


Auditing to tell the Story

Examine

ReviewQuery

Documentation

Review

AbstractTrack

Data

Query

Code

Compare

Identify

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Process Steps to Auditing the Medical Record

1. Examine - The medical record to ensure that it is a complete record. Physician p yattestation statement and Discharge Summary is on the record, as well as nurses notes, treatment records and etc..

2. Review - Must review the Entire Medical Record to accurately assign the principal and secondary diagnosis

3. Abstract- Data from the Medical Recorda. Abstraction Worksheet


Abstraction Worksheet

1. Is there an inpatient admission order for the initial date of service? Yes/No2. What are the documented reasons for admitting the patient to inpatient care?3. On the attestation statement is there a change in the working diagnosis to the principal diagnosis? Yes/No4. What is the principal diagnosis billed on the claim? 5. Is this the same principal diagnosis assigned to the medical record? Yes/No6. Was the patient transferred from another acute care facility on mechanical ventilation? Yes/No 7. Length of stay: ____________________8. What is the documented diagnosis for patient to be on mechanical ventilation?9. Is there any laboratory values to support? ABG’s Yes/No10. Discharge Status

Home or Self Care -01Discharged/ Transferred to a Short Term General Hospital for Inpatient Care -02Discharged/ Transferred to a SNF with Medicare Certification in Anticipation of killed Care - 03Discharged/Transferred to an Intermediate Care Facility - 04g / yDischarged/Transferred to Another Type of Health Care Facility Not elsewhere in the Code List- 05Discharged/ Transferred to Home Care- 06 AMA -07Expired-20

11. Where there any test that revealed any Malignant conditions? Yes/No


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Abstraction Worksheet Cont’d12. Was treatment during stay directed at the Malignant conditions? Yes or No13. Were there any complications noted during stay?

Yes or No14. Date and time if applicable of endotracheal intubation or tracheostomy for ventilation:

________________________________________________________Was this patient transferred to this institution on mechanical ventilation? Yes or No Was patient discharged or transferred while intubated: _____________________If applicable date and time patient was extubated:_________________________Was ET or Tracheostomy performed in inpatient status? ____________________Date and time mechanical ventilation was initiated? _______________________Was patient weaned during time on the vent? If so hours___________________Date and time mechanical ventilation ended:_____________________________Was the patient completely weaned off the vent, and restarted within any time frame during the same admission? Yes or No, If applicable list dates______________________

15. Is there any evidence in the medical record that the patient was only intubated for a procedure? Yes/No16. Is there any evidence in the medical record that the ventilation is due to postoperative complications?17. Was the patient diagnosed with any type of Respiratory Failure? Yes/No

If so; Date and time and list any applicable testing that led to diagnosis __________________________________

18. Was the patient admitted with Respiratory failure or did it develop after admission? Yes/No


Process Steps to Auditing the Medical Record

4. Code - Reviewer will code from data that they abstracted

5. Compare - Codes they assign to the codes that were billedbilled

6. Identify - Any areas in the medical record for areas of uncertainty and discrepancies

7. Track Data Collected- Highlight areas, photocopy areas in question to possibly highlight for physician

8. Query - The provider on any discrepancies found. Send them the highlighted portions of the medical record so g g pthat they can view. DO not lead .. Only identify what is in the record and ask for clarificationa. Statement of Issue or Discrepancyb. Date Initiatedc. Contact person and Infod. Date Query Completed


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The Story

Principal Diagnosis Documentation to support Secondary Diagnosis Procedures MS-DRG


Learning Objectives

Ensure there is documentation in the medical record to support assigning a principal diagnosis within MDC 4support assigning a principal diagnosis within MDC 4

Ensure that there is a definitive diagnosis that affects or will affect the respiratory system to initiate – INVASIVE MECHANICAL VENTILATION (i.e. surgery, respiratory failure, and etc.)

B bl t t k th ti th t h i l til ti i Be able to track the time that mechanical ventilation is initiated to the time that it ends within the institution

Know the difference between Invasive and Non-Invasive Ventilation


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Coding Clinics

Intubation / Mechanical Ventilation Intubation / Mechanical Ventilation /Respiratory FailureAbsence of intubation and mechanical ventilation does not preclude the use of a diagnosis of respiratory failure, 518.8x.

(See Coding Clinic, third quarter 1988, page 7.)

Respirator DependenceCode 46.1, other dependence of machines, respirator, was expanded 10/1/2004 Code46 11 dependence on respirator expanded 10/1/2004. Code46.11, dependence on respirator, status, is only used if there are no complications or malfunctions of respirator and is always a secondary code. Code 46.12, encounter for respirator dependence during power failure, can only be a principal or first-listed code. (DRG 467)

(See Coding Clinic, fourth quarter 2004, pages 100 and 101.)


Coding Clinics

Sequencing of respiratory failure in association with Sequencing of respiratory failure in association with respiratory conditions.The sequencing depends on the reason for admission. Whenrespiratory failure due to an underlying respiratory condition is thereason for the admission, the respiratory failure is the principaldiagnosis. When the respiratory failure develops after admission, it isa secondary diagnosis. When a patient is admitted due to respiratoryfailure and pneumonia, the respiratory failure is sequenced first. Theseconditions are not co-equal. The guideline regarding two or moreinterrelated conditions meeting the definition of principal diagnosisdoes not apply, since this has been specifically addressed in separateCoding Clinic instructions.g

(See Coding Clinic, first quarter 2005, pages 3-8, and CodingClinic, second quarter 2003, pages 21 and 22; Coding Clinic, second quarter 2000, page 21; Coding Clinic, second quarter 1991, pages 3-5; and Coding Clinic, November- December 1987, pages 5 and 6.)


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References

HTTP://LIBRARY.AHIMA.ORG/XPEDIO/GROUPS/PUBLIC/DOCUMENTS/AHIMA/BOK1_043474.HCSP?DDOCNAME=BOK1_043474

HTTP://WWW.COMPLIANCECONCEPTS.COM/PRESSROOM/UNCOVERINGTHEMYSTERYBEHINDTHERACCOMPLEXCODINGREVIEWS.ASP

HTTP://WWW.PEPPERRESOURCES.ORG/LINKCLICK.ASPX?FILETICKET=RK7HAMWQYTU%3D&TABID=75&MID=416


Appealing a Respiratory System Diagnosis

w/ Ventilator Support Denial

Denise Wilson RRT, RN, MISDirector, Client Education

and Performance Improvementand Performance ImprovementIntersect Healthcare, Inc.

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Learning Objectives

• Understand how to create a successful coding or medical necessity appeal for coding or medical necessity appeal for Respiratory System Diagnoses by:– Understanding the issue at hand– Providing a ‘Road Map’ for the reviewer – Presenting a Preponderance of Evidence

• (Best Practice, Regulatory and CMS Guidelines)

• Understand how to tailor appeals to the Administrative Law Judge


Understanding the Issue at Hand

OIG Report on DRG 475 released December 1998– (DRG 475 is now MS‐DRG 207, 208)

DRG 475 was top 5% of DRGs in terms of relative weightrelative weight– http://oig.hhs.gov/oei/reports/oei‐03‐98‐00560.pdf

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Understanding the Issue at Hand

In 1996, it was estimated that 7% of DRG 475 should have been coded to a lower weight DRGshould have been coded to a lower weight DRG

In 1996, Approximately $10,000 difference per case, or $11.5 million

DRG 475 vs. DRG 127 Heart Failure and Shock

High Relative Weight and vulnerable to upcoding


Trending DRG DischargesDepartment of Health and Human Services, Office of Inspector General, Medicare Payments for DRG 475Respiratory System Diagnosis with Ventilator Support, December 1998OEI‐03‐98‐00560

http://oig.hhs.gov/oei/reports/oei-03-98-00560.pdf


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Considerations for Deciding to AppealCost

Planning for Appeals

First Things First Planning

– Cost– Time– Resources– Chance of Overturn– Return on Investment

In addition to:In addition to:– Root Cause Analysis– Education/Remediation Plan


Close examination of decision letter

Building the Foundation

– What are the instructions for appeal?– What forms do I need?– Where do I send my appeal?– What was the issue?

Create Appeal Letter TemplatesCreate Appeal Letter Templates


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Building the Foundation

Copyright 2009 5 412010 Intersect Healthcare, Inc.

http://racb.cgi.com/Issues.aspx

Paint the Picture– Comorbidities and Complications (CC or MCC)

Creating the Structure

Comorbidities and Complications (CC or MCC)– Medical Complexity

Provide a Road Map– Where is the Documentation?

Write to the ALJWrite to the ALJ– Best chance of overturn

Provide a Preponderance of Evidence


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Use the Best Evidence– CMS Internet Only Manuals (IOM)

Creating the Structure


– National Coverage Determinations; Local Coverage Determinations

– ICD-9-CM Official Coding Guidelines– Coding Clinics– Code of Federal Regulations (CFR)

Social Security Act– Social Security Act– Evidence Based Guidelines, Position Statements,

Expert Opinions from National Medical Associations


Providing a Road Map


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Providing a Road Maphttp://www.ama‐assn.org/ama1/pub/upload/mm/362/icd9cm coding g/mm/362/icd9cm_coding_guidelines_08_09_full.pdf


Providing a Road MapICD-9-CM TABULAR LIST OF PROCEDURES (FY10)96.7 Other continuous invasive mechanical ventilationIncludes: BiPAP delivered through endotracheal tube or tracheostomy (invasive interface)…Excludes: non invasive bi level positive airway pressure [BiPAP] (93 90)Excludes: non-invasive bi-level positive airway pressure [BiPAP] (93.90)….Note: Endotracheal IntubationTo calculate the number of hours (duration) of continuous mechanical ventilation during a

hospitalization, begin the count from the start of the (endotracheal) intubation. The duration ends with (endotracheal) extubation.

TracheostomyTo calculate the number of hours of continuous mechanical ventilation during a

hospitalization, begin counting the duration when mechanical ventilation is started. The duration ends when the mechanical ventilator is turned off (after the weaning period).

96.70 Continuous invasive mechanical ventilation of unspecified durationInvasive mechanical ventilation NOS

96.71 Continuous invasive mechanical ventilation for less than 96 consecutive hours96.72 Continuous invasive mechanical ventilation for 96 consecutive hours or more


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• Indications for Mechanical Ventilation– http://www.merck.com

Indications: There are numerous indications for endotracheal

Preponderance of Evidence

– Indications: There are numerous indications for endotracheal intubation and mechanical ventilation but, in general, mechanical ventilation should be considered when there are clinical or laboratory signs that the patient cannot maintain an airway or adequate oxygenation or ventilation. Concerning findings include respiratory rate > 30/min, inability to maintain arterial O2saturation > 90% with fractional inspired O2 (Fio2) > 0.60, and PaCO2 of > 50 mm Hg with pH < 7.25. The decision to initiate mechanical ventilation should be based on clinical judgment that

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mechanical ventilation should be based on clinical judgment that considers the entire clinical situation and should not be delayed until the patient is in extremis.

• Last full review/revision August 2007 by Brian K. Gehlbach, MD; Jesse Hall, MD• Content last modified August 2007


Guidelines on the Management of Community-Acquired Pneumonia in Adults– Time to First Antibiotic Dose

Preponderance of Evidence

Time to First Antibiotic Dose• For patients admitted through the emergency department (ED), the first

antibiotic dose should be administered while still in the ED. (Moderate recommendation; level III evidence)

– Switch from Intravenous to Oral Therapy• Patients should be switched from intravenous to oral therapy when they are

hemodynamically stable and improving clinically, are able to ingest medications, and have a normally functioning gastrointestinal tract. (Strong recommendation; level II evidence)

– Duration of Antibiotic Therapy• Patients with CAP should be treated for a minimum of 5 days (level I

evidence), should be afebrile for 48 to 72 h, and should have no more than 1 CAP i d i f li i l i bili ( T bl b l ) b f

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1 CAP-associated sign of clinical instability (see Table below) before discontinuation of therapy. (level II evidence) (Moderate recommendation)

Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community‐acquired pneumonia in adults.

Mandell LA, et.al; Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community‐acquired pneumonia in adults. Clin Infect Dis 2007 Mar 1;44 Suppl 2:S27‐72. [335 references] PubMed

http://www.guidelines.gov


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Use guidelines in place at the time care was provided

Capping the Issue


Include an Attachments List

Include all Attachments Electronic Copy

Use a Document Editor to Highlight the Medical RecordRecord

Send all Communication via a Traceable Method


MS-DRG 207 slides

Documents

Transcript of MS-DRG 207 slides