Guest Post: A peck of PEPPER, Part 2

by Linda Renee Brown, RN, MA, CCDS, CCS, CDIP

In my previous entry, I talked about the PEPPER process and how it can be used to help identify potential issues of errors in coding, billing, or medical necessity that are specific to each hospital.  Now I want to review some target areas; specifically, stroke/ICH, respiratory infection, simple pneumonia, septicemia, unrelated operating room (OR) procedures, debridements, and DRGs with CCs/MCCs.

Stroke/ICH patients. What is your usual neuro patient population?  Do you treat a large number of stroke/ICH patients, and not so many carotid stenosis or TIA patients?  Check your charts to make sure that traumatic brain hemorrhages are documented and coded differently than non-traumatic brain hemorrhages, as they fall into a different DRG grouping.  Are you querying when it is unclear?  Are you looking at indicators of brain compression and cerebral edema in your radiology reports and then seeking appropriate clinical correlation? Are you erroneously coding brain compression as an MCC on a traumatic brain hemorrhage?

Respiratory infections. This includes aspiration pneumonia, gram-negative pneumonia, and bacterial pneumonia. It also includes cystic fibrosis with pulmonary manifestations, which is a common diagnosis at my hospital. Review records to ensure that the diagnoses are documented correctly and have clinical support.  Verify that complex pneumonias aren’t being coded based on a culture report without physician confirmation.

Simple pneumonia. If your facility is in low outlier PEPPER category for simple pneumonias, take a look at patients discharged with a principal diagnosis of COPD. Are there signs of pneumonia that are being missed? I found it instructive to overlay my hospital’s trends in the simple pneumonia group against the trends in the respiratory infections group. There was a consistent inverse relationship.  When pneumonia was high, respiratory infections were low, and vice-versa.  It made me wonder if we’ve been seeing the same number and type of patients, but diagnosing them or coding them differently.

Septicemia.The percentage in the septicemia group compares diagnoses in the sepsis medical DRGs against the diagnoses in the kidney and UTI DRGs.  If your facility is a high outlier in this target area look at your sepsis cases, especially ones with sepsis due to UTI to be sure that sepsis was documented and coded correctly. If the physician is writing “urosepsis” and there is clinical evidence of systemic sepsis, are you determining if it is UTI or sepsis due to UTI? Is it being coded with sufficient clinical support?  Is a “septic” patient going home in one or two days? If your facility is a low outlier, ask the same question. Are you encouraging the physician to document sepsis due to UTI, rather than urosepsis, when there truly are clinical signs of sepsis?

Unrelated OR procedure. This includes anything that falls into MDC 26, procedure unrelated to principal diagnosis. We already know this is automatically a red flag, so if your facility is a high outlier, meaning a high percentage of your total OR cases are coded into DRG 981-989, you need to take a long, hard look at those cases to be sure the DRG assignment is legitimate. Granted, there are some situations in which the procedure and the diagnosis really are medically related but the codes just don’t fall into place in the same hierarchy. You can rule those out pretty quickly when you audit charts in DRG 981-989.

Excisional debridements. Debridements are fun because you have to involve your surgeons or wound care physicians.  (Fun like root canal work, I’m thinking.)  You don’t want your facility to be a high outlier if  excisional debridements documentation isn’t really that strong. Make sure your operative and procedure notes follow the coding guidelines to the letter before allowing that 86.22 code to go out. You don’t want to be a low outlier because you might be missing excisional debridements that really were performed.  Grab any charts with an ICD-9 CM code of 86.28 (nonexcisional debridement) as principal procedure, especially with a medical DRG, and find out why excisional debridements aren’t being performed or aren’t being correctly documented or even aren’t being correctly coded. In my review, I found cases where the debridement certainly looked excisional, but nobody asked the surgeon or podiatrist. I even found one (and it was mine originally, but now I’ve got that 20-20 hindsight going) where the physician documented that he used a portable curette down to the subcutaneous tissue base, removing all the devitalized unhealthy tissue. Sounds like it could have been an excisional debridement to you? It did to me, too, but what stopped me dead in my tracks was the dictated consult which read, “Nonexcisional debridement was performed.”  It wasn’t until I was auditing the chart months later that it hit me:  the physician almost certainly dictated, “AN excisional debridement was performed,” the transcriptionist heard it as NON-excisional debridement, and nobody fixed it or asked about it, including yours truly.  Ouch!!!

DRGs with CCs or MCCs. I would be worried if my facility were a low outlier on this one. While CCs/MCCs are not my mission in life, nevertheless as a CDI specialist I do expend a significant amount of effort on capturing allowable co-morbidities; if my hospital were below 80% of other hospitals, I’d wonder if I might be missing something. Are charts not being reviewed? Are queries not being asked? Do physicians pull when I push? Is coding reluctant to code certain diagnoses or certain types of documentation? I would be looking at process. Co-morbidities aren’t just about reimbursement; they have a major impact on severity of illness and risk of mortality scores. If I were a high outlier, I’d be worried, too. I’d seriously pull some charts and drill into any chart coded with a single CC/MCC to make sure they’ll stand up to government and payer scruitney.  Actually, even if you’re not high or low, reviewing charts with single co-morbidities is not a bad habit to start, if you’re not already doing it.

Remember to look at your 12-quarter trends. If you see steady change in a positive or negative direction, or big inconsistencies from one quarter to the next, think about what might be happening at your hospital.   Perhaps there are system changes or sudden turnover. If you’re a teaching hospital, do you see a dip when the new house staff come on board? If you focus improvement efforts on a target area, decide what you can impact, determine how much time you’ll realistically need to see a meaningful change and look for evidence of that improvement in a later PEPPER.

One more entry to go. I’ll finish up this series with a discussion of medical necessity target areas, and what we can do with them and for them.

Editor's note: Brown, at the time of the article's original response, was an independent CDI consultant based in Carrollton, GA. With experience in critical care, nursing education, disease management, case management, and long-term care, she has worked as a CDI specialist, educator, director, and consultant. She is a frequent writer on topics involving clinical documentation and published her own "The Case Manager's Quick Guide to Diagnostic Related Groups" in 2013.