News: Retrospective inpatient study finds gradual increase in upcoding for GI surgeries

The number of upcoded cases for patients who underwent gastrointestinal (GI) surgeries increased over a 10-year period, according to  a retrospective study conducted by researchers at Johns Hopkins University School of Medicine in Baltimore, Revenue Cycle Advisor reported. According to the study, which reviewed data from more than a million inpatient stays between 2001 and 2011, an “upcoded” case was one that included more than nine ICD-9-CM codes on the claim.

Researchers collected data from the National Inpatient Sample (NIS)—the largest inpatient administrative database in the U.S., —to target inpatient stays for those over the age of 18 who underwent one of six GI operations (colectomy, rectal resection, gastrectomy, esophagectomy, pancreatectomy, hepatectomy).Researchers then recorded the total number of ICD-9-CM diagnosis codes reported per hospitalization and compared the values to the average number of codes reported for all hospitalizations included in the study. Hospital admissions with greater than the average number of diagnosis codes were classified as upcoded admissions, while those with less than the average number of diagnosis codes were classified as appropriately coded admissions, according to Revenue Cycle Advisor.

Researchers also used recorded hospital charges to estimate the total in-hospital costs for each inpatient admission.

Findings showed that over the 10-year period, the proportion of upcoded admissions (i.e., over nine ICD-9-CM codes reported per admission) increased from 14.1% to 32.9%. The trend was observed for all six GI operations but was greatest for hepatectomy procedures, Revenue Cycle Advisor reported.

Additionally, adjusted analyses showed that upcoded admissions were independently associated with a $13,754 greater in-hospital cost.

According to the 2007 Inpatient Prospective Payment System (IPPS) Final Rule published in the Federal Register, however, there is nothing unethical about submitting more than nine codes, provided they are accurate codes for the patient’s diagnoses. The rule states that:

“We do not believe there is anything inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record…we encourage hospitals to engage in complete and accurate coding.”

Editor’s note: This article originally appeared in Revenue Cycle Advisor. To read the entire study, click here.