Guest Post: Identify sequencing challenges

by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS

Sequencing is a challenge, particularly when two conditions meet the definition of principal diagnosis but only one justifies medical necessity for admission. Many CDI professionals don’t consider the major role sequencing plays in determining whether Recovery Auditors target cases for medical necessity review.

For example, a patient presents with acute exacerbation of chronic obstructive pulmonary disorder (COPD) and acute pneumonia. Both conditions are present on admission (POA), are ­treated equally, and equally qualify as the reason for admission. Coders can select either as principal diagnosis and generally choose the one that yields a higher-weighted DRG. However, if a ­physician doesn’t show the instability of both conditions in clinical ­documentation, auditors opt for the lower-paying one, and sometimes they’re right.

When evaluating cases in which two or more conditions equally meet the definition of principal ­diagnosis, consider which ­actually prompted admission. Would the patient have been admitted for one without the other?

Recovery Auditors don’t just pick these cases out of a hat. They have screens. If we sequence something incorrectly and don’t have the appropriate documentation, then we’re contributing to unnecessary denials. Our goal is not to get the maximum money—it’s to get the optimum reimbursement based on medical necessity and supporting clinical documentation of the same.

Editor’s Note: This article first published in the April 2012 edition of Briefings on Coding Compliance Strategies. At the time of this article's original release, Krauss was Executive Director of the Foundation for Physician Documentation Integrity.