The RAC & Chest Pain MS-DRG 313

Charmira Orr BS, LPN,CCS,CPC, CCDSIntersect Healthcare, Inc

Director of Coding and Auditing

THE RAC and Chest Pain MS-DRG 313

1. Participants will review and understand the RAC and past findings in the demonstration area to assist in preparing a defense

2. Participants will recognize how to translate clinical documentation from the medical record in regards to MI vs. Chest Pain into ICD-9 terminology

3. Participants will understand how to audit the medical record for data pertaining to Inpatient vs. Observation status

22010 Intersect Healthcare, Inc.

Learning Objectives

According to CMS Payment reports in 2007 accounted for 20.1% of paid claim error rates. Ranked #1 of medical unnecessary admissions

In Q1FY10 MS-DRG 313 still ranked #1 for reasons for short stays

National Length of Stay 2.1 days

RW 0.5314

Principal Diagnosis OF MS-DRG 313

- 786.50 Chest pain, unspecified

- 786.51 Precordial pain

-786.59 Chest pain, other

- V71.7 Observation for suspected cardiovascular disease

Targeted by RAC to validate whether “Short Stay” inpatient admissions meet Medicare’s medical necessity criteria


[The RAC and Chest Pain MS-DRG 313]

MS-DRG 313 Chest painDemonstration Findings from NY and Florida : RAC denied many cases based upon the fact that patients did not meet clinical criteria for inpatient care

Great concern for one day stays admissions

Inadequate documentation within the medical record contributed to many of the denials

Coding points for Chest Pain vs. MI

Symptom

Coding and sequencing depends on location and physician documentation

Can be attributed to atypical, musculoskeletal, non-cardiac conditions

Chest Pain

Diagnosis

Coding – to 5th digit to reflect episode of care

Specifity of the wall affected-Electrocardiographic Report

Often consist of the symptom of Chest Pain in which increases in severity

MI

2010 Intersect Healthcare, Inc. 5

Coding for Chest Pain

Principal Diagnosis- The principal diagnosis is the condition that is established after study that is responsible for the admission of the patient to the hospital for care.

Two or more diagnoses may equally meet the definition for principal diagnosis. Be aware that there is a difference between admitting a patient to treat two conditions and two conditions being present at the time of admission.

When reviewing the medical record determine whether or not there were any underlying causes for the chest pain that were documented by the physician.

If a cause was established, the cause of the chest pain is the principal

diagnosis

If the principal diagnosis is observation for a suspected cardiovascular

disease, there should be a ruled out principal diagnosis and no symptoms present.


Observation vs. Inpatient Highlights


Observation Status

Billed under Outpatient Prospective Payment System ( OPPS)

Chest pain is paid under specific observation Ambulatory Payment Classifications (APCs)

Medicare Coverage requires at least 8 hours of monitoring and is limited to 48 hours unless FI grants an exception

The hospital is only paid for 24 hours –

Observation status can be changed to Inpatient Status

Hospitals can convert Inpatient case to Outpatient if determined prior to Patient discharge

N/A - convience, preop, recovery after diagnostic testing, and Inpatient only procedures


ICD- 9 Code V71.7

V71 Category Observation and evaluation for suspected conditions not found

V71.7 Observation for suspected cardiovascular disease

Always Principal Diagnosis

Principal diagnosis for MS-DRG 313

This code would only be used when a suspected cardiovascular condition is ruled out and no

symptoms for the suspected condition are present. If a symptom is present, the code for the

symptom is used and not a code from category V71. (See Coding Clinic, fourth quarter 1994,

page 47.)

Other conditions that co-exist at the time of admission may be coded as secondary diagnoses if they are unrelated to the suspected condition. (See Coding Clinic, fourth quarter 1996, page 53,and Coding Clinic, March-April 1987, pages 1 and 3-5.)

Must only be used after study ,examination, and observation that has ruled out cardiovascular disease

Physician documentation should include findings that suspect abnormal conditions as reasons to why order for Observation status- should include a condition to RULE OUT


Inpatient Status

Admission criteria usually based on Decision Trees/ Criteria

Specific symptom or diagnosis

Should include MD H&P Risk Assessment

Should have detailed findings Labs, radiology to support admission

Auditing the Medical Record

Documentation

Examine

Review

Abstract

Code

Compare

Identify

Track

Data

Query

The Process

1. Examine -The medical record to ensure that it is a complete record. Physician attestation 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 Record – Worksheet


One Day Stay Worksheet

ADMISSION ORDERS: To Where

Observation ( less than 24hours)

1. Does the medical record have an order for observation status? Yes or No

2. What is the documented diagnosis :

3. Does the Attending provider state condition can be treated within 24 hour period? Yes or No

4. If the clinical diagnosis was uncertain at time of order, was it determined within 24 hours or by patient discharge? Yes or No

5. Within the nurses notes is there documentation to support the initiation or arrival of the patient to observation status? If so, date and time:

6. Date and time of the discharge order:

7. Did the patient require a treatment that takes longer than six hours? Yes or No


INPATIENT 1. DOES THE MEDICAL RECORD HAVE AN ORDER FOR ADMISSION TO

INPATIENT STATUS? YES OR NO

2.DOES THIS STAY MEET THE MEDICARE DEFINITION FOR SHORT STAY: ( ONE DAY ADMISSION) YES OR NO3.IS THERE AN ORDER TO CHANGE STATUS FROM OBSERVATION; IF PATIENT WAS IN OBSERVATION? YES OR NO 4.IF PATIENT WAS TRANSFERRED FROM OBSERVATION STATUS; WHAT WERE THE SPECIFIC CONDITIONS FOR THE TRANSFER?5. PRINCIPAL DIAGNOSIS LISTED FOR INPATIENT ADMISSION:6. IS THIS A CHANGE FROM THE ADMITTING DIAGNOSIS? YES OR NO 7.CHRONIC CONDITIONS LISTED AT TIME OF INPATIENT ADMISSION-8.WERE THESE CONDITIONS TREATED DURING THE COURSE OF THE STAY? ( LIST INTERVENTIONS AND/OR TREATMENT OR EVALUATIONS)

Worksheet Continued


9. VITALS AT TIME OF ADMISSION:10. LABS: CARDIAC ENZYMES- POSITIVE TROPONIN LEVELS PT/INR11. WAS ADMISSION SCREENING CRITERIA SUCH AS INTERQUAL OR MILLIMANAPPLIED TO THIS RECORD? YES OR NO 12. WAS IMAGING COMPLETED BEFORE ADMISSION OR ANY THAT RELATES TO ADMISSION13. EKG COMPLETED: ( DOCUMENT RESULTS- ANY FINDINGS OF ISCHEMIA) 14. WAS A CXR COMPLETED, AND IF SO WERE THERE ANY UNDERLYING CONDITIONS THAT WERE NOTED THAT MAY CONTRIBUTE TO THE CHEST PAIN?

YES OR NO15. WERE THERE ANY PROCEDURES PERFORMED WITHIN 24 HOURS OF ADMISSION YES OR NO16. ARE THE PROCEDURES LISTED ON THE APC LIST FOR INPATIENT STATUS ONLY? YES OR NO17.WAS THE PATIENT ADMITTED FOR AN INPATIENT PROCEDURE? AND IF SO 18.WHAT IS THE MEDICAL NECESSARY REASON FOR THE PROCEDURE?19. IS THIS A PROCEDURE THAT COULD ONLY BE PERFORMED ON INPATIENT STATUS? YES OR NO20. DID THE PHYSICIAN LIST ANY DEFINITIVE OR UNDERLYING CONDITIONS FOR THE CHEST PAIN

Worksheet Continued


Worksheet ContinuedReview of the H&P

PMH i.e.… MI’s,

Risk Factors

Physician Treatment Plan

Does the documentation support treatment beyond 24 hours?

Are there any co morbidities listed that will extend patient stay beyond 24-48 hours and additional procedures scheduled?

Patient length of stay;___________ Does this stay correlate with the GMLOS for this DRG? Yes or No

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

Was this record billed with the appropriate status on the claim? Yes or No2010 Intersect Healthcare, Inc. 16

Auditing the Medical RecordContinued

4.Code- Reviewer will code from data that they abstracted5.Compare- codes that they assign to the codes that were billed6.Identify- any areas in the medical record for areas of uncertainty and discrepancies7.Track Data Collected- Highlight areas, photocopy areas in question to possibly highlight for physician8.Query- the provider on any discrepancies found. Send them the highlighted portions of the medical record so that they can view. DO not lead .. Only identify what is in the record and ask for clarification

Statement of Issue or Discrepancy Date InitiatedContact person and InfoDate Query Completed


Telling the Story

Principal Diagnosis Documentation to support Secondary Diagnosis Procedures DRG Assigned

Additional Sign and Symptoms Present on Admission Chronic Conditions Present on Admission

http://www.pepperresources.org/LinkClick.aspx?fileticket=j58QxNsRHRo%3d&tabid=61

http://www.fortherecordmag.com/archives/042610p27.shtml

http://www.pepperresources.org/Data.aspx

http://www.wsha.org/files/64/AHA-PreparingforRACaudits.pdf

http://www.intmed.vcu.edu/home/faculty/billing/observation-inpatient.html#A


References

http://www.pepperresources.org/LinkClick.aspx?fileticket=j58QxNsRHRo%3d&tabid=61

http://www.fortherecordmag.com/archives/042610p27.shtml





http://www.intmed.vcu.edu/home/faculty/billing/observation-inpatient.html



Denise Wilson, MS RN RRTDirector, Client Education and Performance

Improvement

Intersect Healthcare, Inc.

Appealing a Chest Pain One Day Stay Denial

Understand how to create a successful medical necessity appeal for Chest Pain One Day Stay denials by:

Understanding the Issue at Hand

Providing a Road Map for the Reviewer

Presenting a Preponderance of Best Evidence

Understand how to tailor appeals to the Administrative Law Judge


Learning Objectives

According to the most recent Program for Evaluating Payment Patterns Electronic Report (PEPPER) Chest Pain MS-DRG 313 Chest has the highest one-day stay and discharge total per DRG nationwide.

National-level statistical analyses for at-risk payment errors, from Q2FY2009 through Q1FY2010, in short-term acute care hospitals found the sum of Chest Pain One-Day Stay averaged over $26 million per quarter.

Short-Term Q1FY10 Report; Discharges for most recent 4 Quarters, endingQ1 FY2010; Nationwide Top 20 MS-DRGs for One-Day Stays




“Medically Unnecessary Services includes situations where the CERT claim review staff identifies enough documentation in the medical record to make an informed decision that the services billed to Medicare were not medically necessary. In the case of inpatient claims, determinations are also made with regard to the level of care; for example, in some instances another setting besides inpatient care may have been more appropriate. If an FI or MAC determines that a hospital admission was unnecessary due to not meeting an acute level of care, the entire payment for the admission is denied.”

CMS November 2009 Medicare FFS Improper Payments Report



“Medically Unnecessary Service errors accounted for 1.3% of the total inpatient dollars allowed during the reporting period. For inpatient claims, this is often related to hospital stays of short duration where services could have been rendered at a lower level of care.”

https://www.cms.gov/apps/er_report/index.asp




Medicare Benefit Policy Manual Chapter 4 – Section 290 - Outpatient Observation Services

“Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.

Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge.”

“In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours. In the majority of cases, the decision whether to discharge a patient from the hospital…or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours.”



Medicare Benefit Policy Manual Chapter 1 - Inpatient Hospital Services Covered Under Part (Rev. 1, 10-01-03)

“The physician or other practitioner responsible for a patient's care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient. Physicians should use a 24-hour period as a benchmark, i.e., they should order admission for patients who are expected to need hospital care for 24 hours or more, and treat other patients on an outpatient basis. However, the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient's medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital's by-laws and admissions policies, and the relative appropriateness of treatment in each setting.”



Factors to be considered when making the decision to admit include such things as:

• The severity of the signs and symptoms exhibited by the patient;

• The medical predictability of something adverse happening to the patient;

• The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and

• The availability of diagnostic procedures at the time when and at the location where the patient presents.

Admissions of particular patients are not covered or noncovered solely on the basis of the length of time the patient actually spends in the hospital.



From our Appeal Letter Template:

Review of the medical record justifies the need for the level of care provided based on the severity of the signs and symptoms exhibited by the patient and the medical predictability of something adverse happening to the patient as evidenced by the objective findings on the Admission History and Physical and test results as follows:

List all objective findings, 1, 2, 3, etc…

To be completed by the client. (List objective findings)




Providing a Road Map

Use of Screening Tools

Interqual® Level of Care Criteria

Milliman Care Guidelines CMS does not endorse nor recognize specific screening

tool guidelines for admission purposes

PEPPER

http://www.pepperresources.org

Tools/Unnecessary Admissions

Tools/DRG Errors


Preponderance of Evidence

http://www.pepperresources.org/

Evidence Based Guidelines

Goldman L, Kirtane AJ. Triage of patients with acute chest pain and possible cardiac ischemia. Annals of Internal Medicine 2003;139:987-995

ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology. J Am Coll Cardiol 2007 Aug 14;50(7):e1-e157


Preponderance of Evidence

Best Practice for Appeal

Determine if documentation in the chart supports an appeal

Support the physician’s decision making process with evidence based guidelines

Use CMS’s coverage policies and guidelines


Summary

Short-Term Q1FY10 Report; Discharges for most recent 4 Quarters, ending Q1 FY2010; Nationwide Top 20 MS-DRGs for One-Day Stays; http://www.pepperresources.org/Data.aspx

CMS CERT Report from November of 2009; https://www.cms.gov/apps/er_report/index.asp

CMS Manuals; http://www.cms.gov/manuals

Goldman L, Kirtane AJ. Triage of patients with acute chest pain and possible cardiac ischemia. Annals of Internal Medicine 2003;139:987-995

ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology. J Am Coll Cardiol 2007 Aug 14;50(7):e1-e157


Resources



http://www.cms.gov/manuals

The RAC & Chest Pain MS-DRG 313

Health & Medicine

Transcript of The RAC & Chest Pain MS-DRG 313