Does the DRG accurately depict the patient’s story? Does the length of stay and severity of illness correlate with what actually happened?
Although today’s coders face challenging productivity standards daily, asking these questions is an essential and necessary part of maintaining coding compliance, says Heather Taillon, RHIA, manager of corporate coding support services at Franciscan Alliance in Greenwood, Ind. If the answer to either of these questions is “no,” then the principal diagnosis may be incorrect, she says.
The principal diagnosis not only affects MS-DRG assignment, but it also either excludes or includes conditions for core measures reporting, says Cheryl Collins, BS, RN, clinical documentation specialist at the University of Mississippi Medical Center in Jackson.
CMS finalized 35 core measures in the following four categories:
- Acute myocardial infarction
- Pneumonia
- Congestive heart failure
- Surgical Care Improvement Project
Each category includes actions that represent the most widely accepted, research-based care process for appropriate care. For example, congestive heart failure requires evaluation of left ventricular systolic function, treatment with angiotensin-converting enzyme (ACE) or angiotensin receptor blockers, and provision of discharge instructions to the patient.
If coders assign a principal diagnosis in one of these four categories, the following will occur, says Collins:
- Data abstraction will occur upon discharge
- Results will be reported to The Joint Commission and CMS
- Data will be available to the public for comparison
Consider this example: A patient with a history of hypertension complains of shortness of breath. A chest x-ray reveals 3 pillow orthopnea, 3+ pitting edema, and cardiomegaly. An EKG and echocardiogram reveal left ventricular heart failure. Current medication includes beta-blockers, ACE inhibitors, and diuretics. The physician documents left ventricular diastolic dysfunction secondary to hypertension.
As documented—and without further clarification—this maps to 402.90 (hypertensive heart disease without heart failure, unspecified, benign, or malignant). This condition is not a core measure, says Collins. However, if coders clarify whether the diastolic dysfunction is congestive heart failure, the case would be included in core measures reporting.
The following tips can help ensure accurate principal diagnosis selection:
Tip #1: Recognize that the condition that occasions the admission isn’t always the condition that brings the patient to the hospital. Consider this example: A patient presents with fever, gastroenteritis, nausea, and vomiting. After evaluation, a physician determines that the patient is severely dehydrated and admits the patient for administration of fluids.
“Initially, you might think it’s the gastroenteritis [that’s principal], but really, that’s something that could have been treated on an outpatient level,” says Taillon. “The dehydration is really what was causing or necessitating the admission.”
Coding Clinic, First Quarter 2008, pp. 10-11 provides more information about this example.
Tip #2: Proceed with caution when patients are admitted after outpatient surgery. “It’s a tricky situation because a lot of times, physician documentation can be somewhat unclear as to the reason the patient is being admitted,” says Taillon. “In those situations, it’s good to go back and clarify why the patient is being admitted.”
The ICD-9-CM Official Guidelines for Coding and Reporting state that coders should follow these rules when a patient receives surgery in the hospital’s outpatient surgery department and is subsequently admitted for continuing inpatient care at the same hospital:
- Assign a complication as the principal diagnosis when the reason for the admission is a complication of the surgery
- Assign the reason for the outpatient surgery as the principal diagnosis when no complication or other condition is documented as the reason for the admission
- Assign an unrelated condition as the principal diagnosis when the reason for the admission is another condition unrelated to the surgery
It’s always best to clarify whether a condition is related to the surgery, says Taillon. For example, a heart condition may be a complication of surgery, or it may be a chronic cardiac condition that required admission after the procedure. “That’s where the query process really comes into play because you don’t want to assign a complication code if truly it wasn’t a complication of care but rather just a part of the patient’s chronic disease process,” she says.
Tip #3: When coding neoplasms, look closely for the focus of treatment. Neoplasms can be difficult to code because cancer often causes multiple secondary conditions to occur, says Taillon. “Trying to sift through all of the information to come to a principal diagnosis is what makes this somewhat of a challenging process,” she adds.
However, no guideline exists stating that neoplasms take precedence over other conditions, says Taillon. For example, a patient is admitted with hypercalcemia related to multiple myeloma. The focus of treatment is to correct the hypercalcemia. The patient did not receive treatment for the multiple myeloma and was transferred to inpatient hospice thereafter.
In this case, the principal diagnosis is the hypercalcemia because the patient received treatment for this condition despite having the cancer, says Taillon. Coding Clinic, Third Quarter 2012, p. 16 provides more information about this topic.
Many cases may not be as straightforward. For example, a patient presents to the ED with metastatic cancer to his brain and spinal cord. He also has pain that’s out of control and is on oral medication. He requires daily radiation therapy to the spine. The patient is admitted for both IV pain medication and to receive daily radiation treatments. The physician specifically documents the following: “Patient couldn’t withstand traveling daily for outpatient radiation.”
During admission, the patient’s pain is controlled with IV pain mediation converted to oral medication on day three. He completes 12 days of radiation therapy and is then discharged.
The ICD-9-CM guidelines state that coders can assign code 338.3 (neoplasm-related pain) when the stated reason for admission is documented as pain control/pain management. However, in this example, the patient also receives radiation.
“The patient actually stayed in the hospital for 12 radiation therapy treatments. The first three days, he got pain control, but the stay was really 12 days long,” says Taillon. “The reason the patient was admitted was really for the radiation therapy. It was clearly documented by the physician. If we didn’t know that the patient couldn’t withstand [radiation] treatment as an outpatient, we may have leaned toward the symptom or the pain [as principal].”
The difference in payment is significant depending on the principal diagnosis, says Taillon. Reporting the radiation therapy (V58.0) as the principal diagnosis yields MS-DRG 849 (relative weight: 1.3396 and geometric length of stay: 4.6 days). Reporting the sign or symptom without MCC as the principal diagnosis yields MS-DRG 861 (relative weight: 0.7010 and geometric length of stay: 2.7 days).
Tip #4: Choose with confidence when sequencing interrelated conditions. The ICD-9-CM guidelines state that when a patient has two or more interrelated conditions that both meet the definition of principal diagnosis, coders may sequence either condition as principal unless the circumstances of the admission, the therapy provided, or the tabular list or alphabetic index indicate otherwise. Interrelated conditions are those in the same ICD-9-CM chapter. They also include manifestations characteristically associated with a disease process.
Coders sometimes feel trepidation when reporting an interrelated condition that yields a higher-weighted DRG, says Taillon. “Rest assured that if you’ve crossed all of your t’s and dotted all of your i’s and followed all the coding guidelines, it’s appropriate for you to select the higher-weighted DRG. That’s what coding guidelines allow you to do,” she says.
For example, a patient presents with an increase in shortness of breath and edema. An EKG shows atrial fibrillation. A physician documents diastolic congestive heart failure exacerbation and new onset of atrial fibrillation. The patient is placed on telemetry and receives Lasix® and Coreg® for the congestive heart failure. He receives diltiazem and Coumadin® for the atrial fibrillation.
Coders can report either the heart failure or atrial fibrillation as the principal diagnosis, says Taillon. Coding Clinic, First Quarter 2012, pp. 7-8 provides more information.
Editor’s note:The content in this article was originally presented during HCPro’s audio conference, “Principal Diagnosis: Ensure Accurate MS-DRG Assignment.” For more information, visit www.hcmarketplace.com/prod-11178/Principal-Diagnosis-Ensure-Accurate-MSDRG-Assignment.html. This article was originally published in the August issue of Briefings on Coding Compliance Strategies.