A Presentation to the Virginia Health Information Management Association (VHIMA)

1. Commonwealth of Virginia Department of MedicalAssistance Services Division of Program Integrity A Presentation to the Virginia Health Information Management Association (VHIMA) VA DRG Audit Contract

2. AGENDA • Summary of Audit Project • Overview of the VA DRG Audit Program • Sample Letters • Category of Errors • Trending – DRG Coding Errors • Septicemia • Pneumonia • MCCs and CCs • Acute Renal Failure • Acute Respiratory Failure • Kwashiorkor • Other Problem Areas • Provider Responses • Questions

3. Overview of the VA DRG Audit Program • Summary of Medical Record Review • Currently in the 6th Contract Year • 7.5% of all DRG claims selected for review • 90% targeted sample • 10% random sample • AP DRG version 25.1 (beginning 7/1/2010) • Process • Medical Record Request • 30 days to submit medical records • Preliminary Findings Letters • 30 days to submit additional documentation • Final Findings Letters • 30 days to file an informal appeal • Appeal Process

4. Sample Preliminary Findings Letter

5. Sample Final Denial Letter

6. Category of Errors .

7. Trending—DRG Coding Errors The top 9 DRGs listed above account for 25.4%of all the claims with errors.

8. Septicemia • Diagnosis ruled out – especially in newborns/infants • V29.0 Observation for suspected infectious condition • Sequencing (cause of sepsis) • If acute respiratory failure is a result of sepsis, sepsis is coded as the principal • If sepsis is the result of vascular catheters, or urinary catheters, codes related to infection of these devices should be coded first. • Clinical presentation and diagnostic testing • Definition: The presence of bacteria (bacteremia), other infectious organisms, or toxins created by infectious organisms in the blood stream with spread throughout the body. • Systemic illness, patient is acutely ill, sepsis is not a random occurrence • Sepsis is more common in the elderly, individuals with a compromised immune system and persons who are already acutely ill • Sepsis is often misused and misapplied to patients with fever, leukocytosis and hypotension due to other causes • Documentation in medical record should be clear and consistent to support a diagnosis of sepsis

9. Pneumonia • Definition: An infection in one or both of the lungs. Can be caused by bacteria, viruses or fungi. The infection inflames your lungs’ air sacs. The sacs fill up with fluid or pus causing symptoms such as a productive cough, fever, chills and difficulty breathing. • Diagnostic Testing: • National Heart, Lung, and Blood Institute • “A chest x-ray is the best test for diagnosing pneumonia” • Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines: • “In addition to a constellation of suggestive clinical features, a demonstrable infiltrate by chest radiograph or other imaging technique, with or without supporting microbiological data, is required for the diagnosis of pneumonia” • Red Flags: • Physician documents infiltrate on x-ray despite formal chest x-ray report stating, “no infiltrates” • Physician documents pneumonia despite normal chest x-ray, normal white count, etc.

10. Major CCs and CCs • Complications and Comorbidities (CC) • Major CCs • CCs and Major CCs are diagnoses present on a case that significantly increase the expected resource consumption beyond that of the same case with no CCs or Major CCs

11. Acute Renal Failure • Definition: A rapid decrease in renal function over days to weeks, causing an accumulation of nitrogenous products in the blood (azotemia). In all cases, creatinine and urea build up in the blood, and fluid and electrolyte disorders develop. • Diagnoses and Management • Mortality rate is 50-70% • 50% increase in creatinine above baseline • Treat underlying cause • Red Flags: • Physician documents ARI; acute renal injury or acute renal insufficiency • Individual has chronic renal failure and baseline creatinine is not documented, and it is still elevated at discharge • Physician documentation inconsistent

12. Acute Respiratory Failure • Definition: A syndrome in which the respiratory system fails in one of both of its gas exchange functions: oxygenation and/or carbon dioxide elimination • Acute respiratory failure can develop quickly and requires Emergency Treatment • Individual presents with shortness of breath, rapid breathing, bluish color to skin, lips and fingernails, sleepiness and confusion • Requires aggressive treatment (usually in the ICU) • Diagnostic Tests: Arterial Blood Gases • Measures the oxygen and carbon dioxide levels in the blood • Need to diagnosis and treat underlying cause • Red Flags: • Diagnostic testing and treatment not consistent with acute respiratory failure (no ABGs, no increase in oxygen needs, etc) • Physical examinations state, “mild respiratory distress” • Physician documentation inconsistent between acute respiratory failure and acute respiratory insufficiency/distress

13. Kwashiorkor (260) • Definition: Syndrome, particularly of children; excessive carbohydrate with inadequate protein intake, inhibited growth potential, anomalies in skin and hair pigmentation, edema and liver disease. Very rare in the United States • “Protein Malnutrition” • ICD-9-CM book indexes this to code 260 • However, it is described as “Nutritional edema with dyspigmentation of skin and hair” • Coding Clinic Third Quarter 2009 states that it is not appropriate to assign Kwashiorkor (260) if the provider does not specifically document this condition. • “Protein-Calorie Malnutrition” • Codes to 263.x • 260 is a major complication/comorbidity (MCC), 263 is a cc

14. Other Problem Areas • OR Procedure unrelated to principal diagnosis • This occurs, but should be a rare event • Ventilation DRGs • Ventilator substantiated? Hours on vent correct? • Newborn birth weights • Excisional Debridement • Lysis of Adhesions

15. Provider Responses • Provider stating the reassigned DRG is incorrect; Provider did not use the AP Grouper • Stating, “I coded what the physician documented” • Look for language in the denial letter stating, “Following Physician Review….” • Stating what the physician “meant” without submitting the physician query, or a written statement by the physician • Stating Prior Authorization obtained so should be DRG payment (even though no inpatient order or certification of need) • Submission of a medical necessity response (HMS does not review for medical necessity)

16. Questions Kelly Dickson, RN, CFE Project Manager KDickson@hms.com (614) 839-3390