An Update on RACs Activities DRG Validation

Transcription

1 An Update on RACs Activities DRG Validation As of the first of this year, Recovery Audit Contractors (RACs) for Regions C and D announced over 500 Medicare Severity Diagnosis Related Groups (MS DRG) coding audit issues that will require complex review. See Table 1. The MS DRGs listed for potential review represent both medical and surgical cases, and accounts for over 50 percent of the 747 existing MS DRGs. The MS DRGs that may undergo review were approved by the Centers for Medicare & Medicaid Services (CMS). In light of these recent announcements and increased RAC activity, hospitals should ensure that proper audit systems are developed and implemented in order to identify problematic coding issues ideally prior to a RAC or any other CMS contractor review. In a MS DRG validation review, RACs perform an in depth review of the patient's medical records to validate the diagnosis and procedures that were used to establish the MS DRG for the claim billed. The MS DRG code entered determines the correct reimbursement rate provided for the service. At this time, RACs for Regions C and D have announced that they are not examining the medical necessity of the services provided. This article will highlight key vulnerable areas that hospitals should take into consideration, along with some specific tips for identifying problematic MS DRGs. Principal Diagnosis When evaluating hospital claims, RACs assess whether the MS DRG assigned to a claim was correct. Specifically, the RACs will verify if the principal diagnosis reported on the claim is supported by the patient s medical records. The principal diagnosis must be present on admission, contribute to the need for the admission, and be treated during admission. Assigning a principal diagnosis may be clear when a patient is admitted for only one symptom or condition and suffers no complications. However, when situations become more complex, coding the incorrect principal diagnosis can affect the MS DRG assignment as well as the reimbursement rate. Generally, a provider may group an admission to a particular MS DRG based off the combination of the principal diagnosis, any present accompanying complications and/or comorbidities, known major complications or comorbidity (MCC) and complications or comorbidity (CCs), and the principal procedure. In some cases, where there are multiple symptoms, hospitals may choose a principal diagnosis that groups the patient under an MS DRG that is reimbursed at a higher rate. Consequently, Management Systems, Inc. and Atlantic Information Services, Inc.*, th Street, NW, Suite 300, Washington, *Atlantic Information Services is a publishing and information company that has been serving the health care industry for more than 20 years. It develops highly targeted news, data and strategic information for managers in hospitals, health plans, medical group practices, pharmaceutical companies and other health care organizations. AIS products include print and electronic newsletters, Web sites, looseleafs, books, strategic reports, databases, audioconferences and live conferences.

2 2 RACs will be examining the patients medical records to ensure that there is proper documentation to support the reimbursement of the MS DRG. Similar to the RAC Demonstration Project, the RACs will be examining claims involving MS DRGs related to the respiratory system. In cases where ventilator support was used, medical records will be reviewed to validate that the respiratory diagnosis is the principal diagnosis so the higher paying ventilator MS DRG was appropriately assigned (MS DRG 207: Respiratory System Diagnosis with Ventilator Support 96+ Hours). MS DRG 207 was one of the most frequent overpayment collection issues due to incorrect coding in the RAC Demonstration Project. Additionally, the RACs will be tracking MS DRGs where urosepsis and sepsis are coded interchangeably, because technically a finding of urosepsis should code to the lower paying urinary tract infection MS DRG. RACs will also be focusing on scenarios where patients present with two diagnoses requiring equal treatment. An example of such a scenario would be when a patient presents with a seizure and a broken arm. Treatment is given to the patient with respect to both conditions; however, it is unclear which diagnosis should be the principal diagnosis. Generally, these scenarios can be noted using MS DRGs , called non extensive O.R. procedure unrelated to principal diagnosis. However, the use of this overbroad MS DRG creates a ripe target for RACs, who will examine the medical record to certify the documentation meets the definition of the principal diagnosis reported on the claim. Additionally, the RACs will verify that the conditions reported actually required inpatient care. Secondary Diagnosis RACs will also be conducting complex reviews to determine whether the claim was properly assigned the correct MS DRG based on the existence of a secondary diagnosis. For example, if a patient is admitted with sepsis due to an underlying infection, the MS DRG grouping changes depending upon the characterization of the secondary underlying infection. In some cases, the underlying infection should be sequenced as the primary diagnosis (pneumonia), instead of the secondary, depending on the circumstances of the admission. Additionally, some chronic conditions are only sequenced as the principal diagnosis when the patient is first diagnosed. Such conditions, such as cirrhosis and alcoholic hepatitis, should generally be categorized as chronic conditions, which do not usually occasion an admission in the absence of an acute condition. Generally, RACs are looking to make sure coders do not assign MS DRGs based on higher paying chronic conditions instead of lower paying acute conditions. Procedures Codes RACs will also be examining medical records to verify that all the requirements for specific MS DRG procedural codes are present. Several MS DRGs have age, time and place, or specific procedural requirements that must be met and documented within the patient s medical records. For example, several ventilation MS DRGs must be assigned depending on whether the patient was on a ventilator for more or less than 96 hours. Additionally, for MS DRGs involving major gastrointestinal disorders and peritoneal infections there are documentation requirements for C. difficile lab results to be specifically linked to the colitis, as those that are not, fall under a lower paying DRG. Finally, when performing lung biopsies, the surgeon must specifically note that lung tissue was collected and removed to qualify for

3 3 the surgical, and higher paying, MS DRG. Otherwise, the procedure is categorized as a bronchoscopy, which is not a surgical procedure and therefore triggers a lower paying, medical MS DRG. Length of Stay Both the Regions C and D RACs were approved to conduct complex reviews for MS DRGs 291 (Heart failure and shock with MCC), 292 (Heart failure and shock with CC), 293 (Heart failure and shock without CC/MCC), and 313 (chest pain). According to the TMF Health Quality Institute's (CMS Contractor)"Shortterm, Acute Care Program for Evaluating Payment Patterns Electronic Report (ST PEPPER) User's Guide," short inpatient hospital stays related to chest pain, heart failure and shock are identified as target areas for inpatient claims. Questions regarding upcoding and whether the services were rendered in the correct setting arise when a beneficiary is admitted and discharged in a short period of time (e.g. one day stay). As a result, the RACs may review the medical records particularly in cases where a MS DRG reimbursed at a higher rate are reported with a short stay or a length of stay that is different from the average length of stay for the MS DRG. They may assess if the medical documentation supports the assignment of the higher payer MS DRG. Providers are encouraged to audit their inpatient claims reporting short length of stays. When auditing inpatient claims, providers should identify the average length of stay which is noted in the MS DRG definition. For example, MS DRG 293 has a geometric mean length of stay (GMLOS) of 3.1 days. However, MS DRG 291 has a GMLOS 5.1. Therefore, in the event an inpatient claim reporting MS DRG 291 has a length of stay for 3 days, the provider may wish to review the medical records to ensure that the documentation supports the claim. This auditing process can also be done for MS DRGs 391 (esophagitis, gastroenter, & misc digst disorder with MCC), 392(esophagitis, gastroenter, & misc digst disorder without MCC), 640 (nutritional & misc metabolic disorders with MCC), and 641(nutritional & misc metabolic disorders without MCC). Patient Discharged Status Codes The RACs will also validate if the discharged status code reported on the claim matches the attending physician description and the information contained in the patient s medical record. CMS has issued guidance to providers to clarify the rules governing patient discharge status codes and hospital transfer policies. CMS notes in its correspondence that it is important [for provider] to select the correct patient discharge status code [because] apply the correct code will help assure that the provider receive prompt and correct payment. 1 In its guidance, CMS states that [i]n cases in which two or more patient discharge status codes apply, providers should code the highest level of care known. 2 Thus, the RACs may review medical records to ensure that the discharged status code reported on the claim supports the highest level of care known. 1 Clarification of Patient Discharge Status Codes and Hospital Transfer Policeis JA0801. MLN Provider Inquiry Assistance: SE0801 Revised. 23 Jan Ibid.

4 4 CMS has also indicated in its correspondence to providers, clarification with respect to discharge status codes 50 and 51. Providers should report discharge status code 50 if a patient is released to his/her home or an alternative setting such as a nursing facility and will receive in home hospice services. Patient discharge status code 51 should be used if a patient is discharged from an acute hospital but will remain in the same hospital under hospice care. Patient discharge status code 51 can also be used if a patient is transferred from an inpatient acute care hospital to a Medicare certified SNF under certain conditions. 3 Overall, although it not clear what the RACs are assessing with regards to patient discharged status codes, providers may wish to do perform an audit on a sample of claims and verify that the medical documentation support the reported discharged status code. Take Home Message As noted above, CMS has approved over 500 MS DRGs to undergo medical record review. Providers should be proactive and review their claims for accurate coding particularly with respect to the approved DRG validation issues. It should be noted that though the DRG validation issues were only approved for Regions C and D, providers in Regions A and B should be aware of the approved issues since their RACs may soon follow. Table 1 outlines the MS DRGs Regions C and D RACs may assess. Table 1: CMS Approved MS DRGs Amputation Burns Cardiac Procedures Continued Cardiac Procedures Cardiovascular Disease Blood & Immunological Disorders For additional information, providers are encouraged to review Clarification of Patient Discharge Status Codes and Hospital Transfer Policeis JA0801. MLN Provider Inquiry Assistance: SE0801 Revised. 23 Jan

5 Blood & Immunological Procedures Cardiovascular Disease Continued Table 1 Continued: CMS Approved MS DRGs Eyes, Nose, Mouth, & Throat Procedures Female Reproductive System Procedures Continued Endocrine, Nutritional, & Metabolic Disorders Gastrointestinal Disorders Cardiovascular Procedures Eye Procedures

6 Female Reproductive System 383 Procedures

7 7 Table 1 Continued: CMS Approved MS DRGs Gastrointestinal Disorders Continued Gastrointestinal Procedures Continued Gastrointestinal Procedures Continued Health Status Factors Infection Gastrointestinal Procedures Kidney & Urinary Track Disorders Table 1 Continued: CMS Approved MS DRGs

8 8 Kidney & Urinary Tract Disorders Continued Male Reproductive System Procedures Continued Kidney & Urinary Tract Procedures MDC 04 Respiratory Continued Malignant Breast Disorders MDC 04 Respiratory Mental Disease and Disorders Male Reproductive System Procedures 187 Multiple Significant Trauma Procedures

9 9 Table 1 Continued: CMS Approved MS DRGs Multiple Significant Trauma Procedures Continued Nervous System Disorders Nervous System Disorders Continued Neoplasm Nervous System Procedures Neoplasm Surgery OR Procedure Unrelated to Principal Diagnosis

10 10 Table 1 Continued: CMS Approved MS DRGs OR Procedure Unrelated to Skin Graft & Connective Tissue Transplants Continued Principal Diagnosis Continued Postoperative or Post traumatic 581 Infection Procedures for Injuries Spinal Fusion Septicemia Skin Graft & Connective Tissue Transplants

11 Official Resources Connolly Healthcare Inc Website. 15 Dec < HealthDataInsights. 15 Dec < Clarification of Patient Discharge Status Codes and Hospital Transfer Policeis JA0801. MLN Provider Inquiry Assistance: SE0801 Revised. 23 Jan