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Uncovering the Mystery behind the RAC Complex Coding Reviews
 

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This article was originally published in the American Health Information

Management Association (AHIMA) January 2010 newsletter.

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by Donna D. Wilson, RHIA, CCS

Connolly Healthcare (recovery audit contractor for Region C) recently published the first set of Centers for Medicare and Medicaid Services (CMS) Approved Audit Issues for complex reviews. The complex reviews will request medical records to validate coding and DRG assignment, as well as the discharge status code assignment, for the MS-DRGs/DRGs displayed in figure 1.1. (It should be noted that these complex reviews approved by CMS do not include medical necessity determination.)

On December 3, 2009, coding experts in Region C started analyzing the patterns in the above listed MS-DRG pairings. Below are some questions to consider as to why these MS-DRGs were chosen for review:

Major Chest Procedures (MS-DRGs 163-165) Include Open Lung Biopsies:

  1. Was the approach (open or closed) documented and coded appropriately?
  2. Is there sufficient documentation to support the site of the biopsy?
  3. Was the operative procedure coded correctly?
  4. Are coders following AHA Coding Clinic advice? Refer to Second Quarter 2009.

Other Respiratory System Operating Room Procedures (MS-DRGs 166-168):

  1. Did the patient have an excisional debridement? (Keep in mind lung diagnoses with excisional debridements group into MS-DRGs 166-168, not into the Debridement MS-DRGs.)
  2. Was the procedure a transbronchial lung biopsy?
  3. Was the correct site of the biopsy coded correctly? For example: Closed endoscopic biopsies of the lung fall into MS-DRGs 166-168 but Closed endoscopic biopsies of the bronchus do not.
  4. Are coders following AHA Coding Clinic advice? Refer to Fourth Quarter 2007.

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

  1. Are the hours on ventilator support calculated correctly?
  2. Do you have sufficient documentation to support the 96+ hours on ventilator support?
  3. Are coders following AHA Coding Clinic advice? Refer to Fourth Quarter 1991.

Upper Limb and Toe Amputation for Circulatory System Disorders with MCC (MS-DRG 255):

  1. Was the operative coded correctly based on the documentation within the body of the operative report?
  2. Was there sufficient documentation to support the major complication or comorbidity (MCC)?
  3. Are coders following AHA Coding Clinic advice? Refer to First Quarter 2005.

Major Small and Large Bowel Procedures (MS-DRGs 329-331):

  1. Was the ICD-9-CM procedure code assigned correctly based on the documentation within the body of the operative report? For example, codes 46.79 (other repair of the intestine) or 46.99 (other operations on intestines) are vague procedure codes and can easily be miscoded when unclear documentation is found within the medical record. When in doubt, query the physician.
  2. Was there sufficient documentation to support the MCC and/or the complication or comorbidity (CC)?

Digestive /Hepatobiliary System (MS-DRGs 372, 386, 394, and 432):

  1. Did the coder inadvertently omit a procedure code assignment on these GI/liver diagnoses?
  2. Was there sufficient documentation to support the MCC and/or the CC?

Coagulation Disorders (MS-DRG 813):

  1. Are coders assigning 286.5 on all patients who are on anticoagulants?
  2. Are coders following AHA Coding Clinic advice? Refer to Third Quarter 1990, Fourth Quarter 1993, and Third Quarter 2004.

Septicemia without Mechanical Ventilation 96+ Hours (MS-DRGs 871-872):

  1. Does documentation within the medical record support the clinical diagnosis of sepsis?
  2. Has the physician been queried in reference to his clinical diagnosis of urosepsis?
  3. Are coders following AHA Coding Clinic advice? Refer to Fourth Quarter 1991 (regarding ventilator hours).

Extensive and Non-extensive Operating Room Procedure Unrelated to Principal Diagnosis (MS-DRGs 981-983 and 987-989):

  1. Was the correct principal diagnosis assigned utilizing the definition of principal diagnosis according to AHA Coding Guidelines?
  2. Does the facility perform second-level reviews on these MS-DRG groupings to ensure accurate code and DRG assignments?

Also, remember that the discharge disposition code assignment will also be validated. Was the MS-DRG under the Post Acute Transfer Payment Policy during the fiscal year of the claim submission? See figure 1.2 created by Diane Paschal, director of corporate compliance at South Carolina Hospital Association.

The questions above are listed to serve as a guide. They should not be considered the only area of review of the recovery audit contractors. Each medical record will stand on its own as far as documentation to support the coding. Remember when appealing these denials to refer to the AHA CC that was in effect at the time of patient’s discharge.

Reference

Connolly Healthcare. Available online at http://www.connollyhealthcare.com/RAC/pages/approved_issues.aspx.

Donna D. Wilson (dwilson@ccius.com) RHIA, CCS, is a senior director at Compliance Concepts, Inc.

 

 

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