Identify potential DRG problems and audit targets

 

Striving for the correct DRG assignment on the first pass should be every coder’s goal. This is not simple, and a close look reveals that the complexity of coding rules and the quality of documentation in facilities sometimes make correct DRG assignment a daunting task. Expert knowledge of the ICD-9-CM Official Guidelines for Coding and Reporting and a clear understanding of the clinical documentation necessary are essential elements for assigning the correct MS-DRG.

 

Some MS-DRGs are more complex and prone to error than others. Preventing negative findings by Recovery Auditors or other CMS payment monitoring agencies requires careful attention to the DRGs, or MS-DRGs, that these agencies have targeted in current and past claims within the look-back period. What can facilities do to identify and manage these MS-DRGs that are prone to error?

 

One method for identifying error-prone MS-DRGs is through use of the Program for Evaluating Payment Patterns Electronic Report (PEPPER) report. The PEPPER report provides organizations with insight into potential vulnerabilities that may result in denied claims and recoupment. PEPPER short-term acute care hospital targets include:

 

Recovery Auditors also focus on DRG assignments and often request records for error-prone DRGs.

 

Facilities can use PEPPER data to identify outliers and act upon them. Data found in the PEPPER report is based on paid Medicare claims and has a ranking system that includes all organizations receiving Medicare payments. With this information, outliers can be identified. Medicare also provides a quarterly analysis of hospital-specific Medicare inpatient claims that are vulnerable to improper payment, including potential overpayments and underpayments.

Recovery Auditors are scrutinizing MS-DRG 069 . The correct coding of transient ischemic attack (TIA) or cerebrovascular accident (CVA) is an important compliance issue. Recovery Auditors are reviewing physician documentation to determine that services provided were medically necessary and billed correctly. Documentation from the time of the patient admittance is not always clear; sometimes the provider documents TIA vs. CVA or R/O CVA. These patients are often admitted with altered mental status, often somnolent or unresponsive.

 

Stroke symptoms lasting less than one hour are TIAs. Strokes damage brain tissue, but TIAs often do not. When damage does occur, it is less severe than damage caused by a stroke. A coder must be savvy enough to determine from the physician progress notes and other documentation whether the correct diagnosis is CVA or TIA. If that is not possible, a physician query is appropriate to determine which diagnosis to code. Facilities should consider performing a focus review on their cases that fall into the category of MS-DRG 069. Coders should regularly review the ICD-9-CM Official Guidelines for Coding and Reporting cerebral infarction/stroke/cerebrovascular accident.

 

Gastrointestinal (GI) MS-DRGs 378, 377, and 376 are also tricky. GI bleeding can be chronic, caused by a hemorrhoid or an ulcer, or acute. It is essential for physicians to document the pertinent clinical findings on admission. If physicians don’t connect the dots and tell the whole story, coders will need to query them in order to assign the correct codes for the GI bleeding and anemia if present. The physician must also document the etiology of the bleeding, if known. To support admission for GI bleeds, the physician must tell the whole story between the patient’s symptoms and the need for acute care. Coders should regularly review the ICD-9-CM Official Guidelines for Coding and Reporting of signs/symptoms and anemia.