Most grouper software in encoders is designed to pull the procedure that impacts DRG assignment into the first position. While the definition was in place prior to ICD-10 implementation, it was not part of the official coding guidelines. Check your code book to determine if the most recent ICD-10-PCS guidelines are included up front. In most cases, that logic would be correct. Lack of accuracy and compliance with current coding guidelines and clinical documentation procedures always results in significant negative impacts to organizations revenue streams. This requires more time to accurately code each case with five points in mind: It is the coders responsibility to code with integrity, aimed at reduced compliance risk and maximum reimbursement. DRG 455, combined anterior/posterior spinal fusion without CC or MCC, is a common example of a miscoded surgical approach or technique code assignment. The ICD-10procedural coding system is more granular and based on entirely different decision trees than its ICD-9predecessor. Copyright 2022 HCPro, a Simplify Compliance brand. Medicare physician payments would decrease by more than 4% in 2023, according to a proposed rule. Confirm that all diagnoses are supported by clinical documentation that is complete and legible and query providers if documentation is unclear. In ICD-10, coders are required to fully understand the procedures performed. Inclusion of clinical documentation improvement specialists and physicians is recommended as part of an organizationwide denials prevention program. There are several reasons why DRG 226and DRG 455emerged as troubling areas for payment. Excisional debridement not related to the principal diagnosis. Coding managers should assess coder knowledgeby providing coding teams with the same set of sample cases. Coders must select and assign codes in the correct order to guarantee the highest level of payment while also ensuring compliance with correct coding guidelines. This critical revenue cycle process codifies the clinical care performed and documented. The debridement code drives the MS-DRG assignment since it is an OR procedure: MS-DRG 166, other respiratory system, or procedures with MCC. For example, when ICD-10code 0JH608Z, Insertion of Defibrillator Generator into Chest Subcutaneous Tissue and Fascia, Open Approach, is reported alone, DRG 245AICD Generator Procedures is assigned. Coding accuracy directly affects attainment of these goals. The preceding example is one of many. Both the feeding tube placement and laparoscopy codes are OR procedures under MS-DRGs. MedLearn Media, Inc.445 Minnesota Street, Suite 514St. However, there are unusual cases in which a procedure (one that does not meet the definition of principal procedure) is pulled to the top because it affects the DRG assignment. Are there any issues ofCoding Clinicthat give more information regarding the assignment of a principal diagnosis? Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. The diagnosis reflects the reason the patient sought medical care, and the principal diagnosis can drive reimbursement. ), then refer to Section II, subsections B, C, D, and E, in the ICD-10-CM coding guidelines. 2022 Healthcare Financial Management Association, Healthcare Financial Management Association. Sequencing of codes drives the selection of the principal diagnosis, especially if there are co-existing conditions present on admission (POA). Correct coding and DRG assignments for these cases requires closer scrutiny of operative reports and deeper understanding by clinical coders. Are there any instructional notes or chapter-specific guidelines that give sequencing direction for coding? For example, say a patient with malnutrition is admitted for placement of a percutaneous endoscopic gastrostomy (PEG) tube and medical management for failure to thrive. Avoid relying solely on the encoder or electronic health record for final code assignment, which is especially true for any CC/MCC secondary diagnoses that meet the definition of a reportable diagnosis. Though arbitration cases are expected to be addressed in a slow fashion at first, there may be some related regulatory changes that favor providers, Nick Hut reports. The study reveals growing concern for coding quality and correct DRG assignment. The selection of the principal diagnosis is one of the most important steps when coding an inpatient record. If there are no chapter-specific guidelines for sequencing (is the patient pregnant? Operative reports for these patients should specify both anterior and posterior approachesand both must be coded correctly. While procedures under ICD-9required only a single code, ICD-10 requires multiple codes. DRG 455, combined anterior/posterior spinal fusion without complication or comorbidity (CC)/MCC, carried an even higher potential reimbursement loss of $9,196per case when coded inaccurately. , Excision of buttock skin, external approach, , Pressure ulcer of unspecified buttock, stage 3. Whether performed by internal coding experts or an external business partner, DRG accuracy audits should be conducted at least quarterly to determine financial impacts that result from incorrect DRG assignments. These digits represent initial, subsequent, or sequela. Here are three such topics that have captured our attention. Multiple factors must be considered and reviewed before a coder can assign a diagnosis as principal. Multiple OR procedures with incorrect sequencing. Identify CCs and MCCS and ensure all codes are sequenced correctly. As part of ongoing training and education, conduct audits based on industry requirements to confirm correct sequencing and improve coding performance. But our work isnt done after that. These include missed procedure codes and incorrect surgical approaches or techniques. Coders and CDI professionals must review all the documentation by the physician or any qualified healthcare practitioner who, per the coding guidelines, is legally accountable for establishing the patients diagnosis. You have [n] free articles remaining this month. Heres a simple example. Coders can no longer rely solely on discharge summaries or other review reports to correctly assign codes. No Repeal and Replace: Value-Based Purchasing Moves Forward into a New Arena with Skilled Nursing Facilities, ICD-10-PCS Principal Procedure Selection: Ensuring Proper Sequencing. Unfortunately, the laparoscopic procedure has to be converted to an open procedure. All three procedures are OR procedures in the APR-DRG system. These notes, usually printed in red, give sequencing guidance for codes in this category. A new study quantifies the extent to which treating disease has become increasingly expensive since just before the turn of the century. Coders must also understand the devicespacemakers versus defibrillators. Develop a procedure sequencing checklist as a quick reference for coders. Also, identify areas for improvement based on specific knowledge and skills gaps. Coders, coding management, and revenue cycle leaders all contribute to successfully protecting revenue and mitigating risk in ICD-10. The report identified two inpatient DRGs with particularly high potential for revenue loss due to poor coding accuracyDRG 226and DRG 455. More extensive record reviews. However, when code 0JH608Z is reported along with code 0JPT0PZ, Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Open Approach, to indicate a generator replacement, a DRG for Cardiac Defibrillator Implant (DRGs 226through 227) is assigned, resulting in a higher payment to the facility. Incorrect surgical approach or technique. In this case, the principal procedure is the feeding tube placement (0DH60UZ, Insertion of feeding device into stomach, open approach) since it is the most definitive procedure related to the principal diagnosis. In ICD-10, it is best practice to review the entire medical record versus only summary documents. Sometimes the book is published before the latest version of the guidelines is released. Coding accuracy will become even more important as the Centers for Medicare & Medicaid Services and other payers expand value-based reimbursement and as ICD-10codes form the foundation for accurate quality reporting. Inpatient coders have a critical responsibility to ensure the accuracy of DRG assignments. Sequencing directly affects compliance and core measures that rely on the principal procedure field. A subcutaneous continuous infusion catheter is also placed during surgery for postoperative pain management. by Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP. Accurate coding is required for proper billing, reimbursement, and compliance. Parts of the medical record include the history and physical, progress notes, orders, consultation notes, operative reports, and discharge summary. implants and anterior/posterior spinal fusionthat can result in significant revenue loss. Decompensated, according toCoding Clinic, Second Quarter 2013, indicates that there has been a flare-up (acute phase) of a chronic condition. It is also included in some of the core measures from the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission. Replacement, revision, repositioning, insertions, and upgrades are all variables that can affect DRG assignments. Multiple positions and techniques are commonly used by surgeons, but not thoroughly understood by most coders, resulting in frequent miscoding and improper DRG assignments for DRG 455. However, before assigning that code as the principal diagnosis, you must check the instructional notes directly under category I50 for heart failure. Accuracy is becoming increasingly critical to value-based payment, improved patient outcomes, and maintaining high-quality care. These misplaced procedures do not meet the principal procedure definition set forth by coding guidelines. coding quality with special emphasis on two inpatient DRGscardiac defibrillator Missed or incorrect procedure codes. Stay current on coding guidelines as codes are updated every October and new American Hospital Association Coding Clinics are released quarterly. The DRG-impacting code must be in the top six I recommend spot No. Subscribe to receive free ICD-10 news and updates. We all know that proper sequencing of the principal diagnosis is one of the keys to accurate MS-DRG assignment, but how much effort do we put into sequencing procedures? Assess coder knowledge. Per theOfficial Guidelines for Coding and Reporting, code first informs coders that these conditions have both an underlying etiology and multiple body system manifestations due to that etiology: For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Additional codes include the laparoscopic portion before it was converted to an open procedure (0WJG4ZZ, Inspection of peritoneal cavity, percutaneous endoscopic approach) and placement of the subcutaneous catheter (0JHT03Z, Insertion of infusion device into trunk subcutaneous tissue and fascia, open approach). Groupers pull the OR procedures to the top of the procedure list, but if theres more than one, they dont resequence those codes. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.. Correct procedural sequencing places the ventilator first, since it was a definitive procedure performed to treat the respiratory failure. A new study reveals growing concern for ICD-10 This happens when a procedure is designated as a surgical procedure but the principal procedure, according to the definition, is a nonsurgical procedure. While this is not new to PCS, it remains a sequencing issue that we often see. A best practice is to pull the current version from the CMS website. Seventh characters. For example, if a patient is treated for decompensated diastolic congestive heart failure and also has hypertension, instructional notes within Chapter 9 of the ICD-10-CM manual, Diseases of the Circulatory System, give sequencing directives for the coding of these conditions. Answers should be compared with expert-vetted answer keys to score performance. Operative notes are complex. While grouping errors may not be new with ICD-10 implementation, the addition of principal procedure definitions to the guidelines has brought the issue to the forefront. While coders are keenly focused on sequencing diagnoses, many have not considered the possibility of a procedural sequencing error. Beyond new complexity in procedure coding, code sequencing, the use of a seventh character in ICD-10, and the need for more extensive record reviews all contribute to coding accuracy. Its definitions are used by acute care hospitals to report inpatient data elements that factor in the DRG classification system, which is how the hospital receives reimbursement for the inpatient admission. In reference to the example above, congestive heart failure with hypertension, documentation guidelines for reporting these two conditions have changed for 2017. Powered by MedLearn Media. The definition of a principal procedure is part of the Uniform Hospital Discharge Data Set (UHDDS): the standard set of data elements used for inpatient billing and statistical information. Arterial monitoring has been listed as an OR procedure that may be sequenced before non-OR procedures that meet the principal procedure definition. Contact her atacommeree@hcpro.com. Wherever such a combination exists, there is a use additional code note at the etiology code, and a code first note at the manifestation code. Download education offerings. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. Many encoders will sequence the debridement code as the principal procedure. As shown in the examples above, coders must make sure the DRG-impacting procedure is on the bill, though it doesnt have to be listed first. Power your potential and improve the health of your team, your organization, and your career. COPD and Pneumonia: Code First or Code Also? A thorough review of the documentation, along with a solid understanding of theOfficial Guidelines for Coding and Reporting, instructional notes, andCoding Clinicissues, is imperative. It is important for revenue cycle executives to monitor and improve accuracy for these two DRGs as part of a complete denials prevention or management program to protect reimbursement and mitigate audit risk. The procedure code for a hysterectomy is automatically pushed to the first procedure position, and its also the code that drives DRG assignment. Since ICD-10 implementation, one of the areas where we often see coding errors is in the assignment of the first-listed procedures. 2 if it doesnt meet the principal procedure definition. Copyright 2022 ICD10monitor. Consider the case of a patient with uterine cancer who undergoes a hysterectomy. There may be many reasons a patient went to the hospital, and multiple conditions may have been treated during that patients stay. Some hospitals are moving to monthly external audits to remediate errors before they escalate. By Eileen Dano Tkacik and Kim Charland RHIT, CCS, Business Partner & Marketing Opportunities. But were still not done. DRG 226, cardiac defibrillator implant without cardiac catheterization with major complication or comorbidity (MCC), carried a potential reimbursement loss of $8,790per case due to poor coding quality and faulty DRG assignment.