MS-DRGs

1. MS-DRGs Kiwi-Tek Webinar Session 2 August 2009 Joy King, RHIA, CCS Karen Scott, MEd, RHIA, CCS-P, CPC Joy King Consulting, LLC

2. Pneumonia An acute inflammation of alveoli & terminal lung spaces due to infection • S/S: malaise, fever, dyspnea, cough, sputum production, pleuritic chest pain, confusion and/or obtundation w/o respiratory symptoms • Findings: infiltrate on CXR (gold standard), RR > 25, HR > 100, rales, crackles, rhonchi, dullness to percussion, decreased breath sounds Joy King Consulting, LLC

3. Pneumonia • Community-Acquired (CAP): infection in patient who was not hospitalized or residing in LTC 14 or more days prior to infection • Hospital-Acquired (HAP): infection 48 hrs or more after hospitalization in patients w/ no previous infection. Early onset w/in 1st 4 days of hospital stay, late onset after 4 days • Vent-Associated (VAP): occurs 48-72 hrs after endotracheal intubation • Healthcare-Associated (HCAP): develops w/in 90 days of a > 2-day stay; or in NH or LTC resident; or w/in 30 days of IV abxtx, chemo or wound care; or following clinic or HD visit; or contact w/ multi-drug resistant (MDR) pathogens Joy King Consulting, LLC

4. Healthcare-Associated Pneumonia (HCAP) • Srep pneumoniae (gram +) • Drug-resistant Strep pneumoniae (DRSP) • Hemophilus influenzae (gram -) • Moraxella catarrhalis (gram -) • Staph aureus (gram +) • Klebsiella pneumoniae (gram -) • MRSA (gram +) • Acinetobacter (gram -) Initial Tx: broad-spectrum abx--all HCAP patients presumed to be infected w/ MDR pathogens, considered high-risk, & usually admitted Joy King Consulting, LLC

5. Pneumonia • Simple Pneumonia: Streptococcal, Pneumococcal, H. flu, Mycoplasma—if patient only on Levaquin, Rocephin or Zithromax, probably NOT complex • Viral Pneumonia: 480.x (now an MCC)—mucopurulent sputum, pleuritic CP, neg bacterial smears, interstitial pneumonia on CXR, chills, rales, hypotension, headache—tx w/ Amantadine, O2, nebulizer • Complex Pneumonia: Klebsiella, H parainfluenza, Legionella, Moraxella, Pseudomonas, S. aureus, gram -, anaerobes, aspiration, TB, fungal Joy King Consulting, LLC

6. Pneumonia Look at organism on sputum c/s & abx: • Aspiration Pneumonia—Clindamycin, Unasyn, Zosyn • Gram-negative—Zosyn, Gentamicin, Tobramycin, Amikacin, Ceftazidine, Ciprofloxacin, Primaxin, Tygacil • S. aureus (including MRSA)—Clindamycin, Unasyn, Zyvox, Vancomycin • Enterococci—Zyvox, Vancomycin Joy King Consulting, LLC

7. Aspiration Pneumonia MD must link aspiration & pneumonia • Most commonly in rt lower lobe (> 50%) • S/S: sudden onset dyspnea—CXR findings, leukocytosis & fever may lag behind; “silent” aspiration often cause of recurrent asthma, COPD or CHF; nocturnal wheezing; non-cardiogenic pulmonary edema • Risk factors: GERD, elderly, stroke w/ dysphagia, other swallowing disorders Joy King Consulting, LLC

8. MS-DRG Options Simple Pneumonia (DRG 89, r.w. 1.0376) MS-DRG 193 w/ MCC 1.4327 MS-DRG 194 w/ CC 1.0056 MS-DRG 195 w/o CC 0.7316 Complex Pneumonia (DRG 79, r.w. 1.6268) MS-DRG 177 w/ MCC 2.0393 MS-DRG 178 w/ CC 1.4983 MS-DRG 179 w/o CC 1.0419 Joy King Consulting, LLC

9. Pneumonia Coding Issues • Lack of documentation of cause • Co-existing conditions, such as sepsis, on admission and lack of MD documentation to determine sequencing as PDx or secondary dx • Symptoms overlapping w/ other forms of respiratory disease such as acute bronchitis and COPD Joy King Consulting, LLC

10. CAD & Related Conditions • Chest Pain: document causes, such as chest wall pain, costochondritis, GERD, cholelithiasis esophagitis, CAD, Syndrome X, coronary vasospasm, pulmonary embolus, aortic dissection • Stable Angina I = none w/ inactivity, present if strenuous 413.9 II= early onset w/ regular activity 413.9 III= marked limitation of activity 413.9 IV= angina at rest (angina decubitus) 413.0 (CC) Joy King Consulting, LLC

11. CAD & Related Conditions • Unstable Angina: occurs at rest & lasts > 20 min OR severe, described as flank pain, starting w/in past month, OR crescendo pattern—411.1 (CC) • Non-Q wave MI: elevation of cardiac enzymes (troponin 1 > 0.4 mg/dL) in setting of angina symptoms, EKG changes, or other cardiac manifestations—410.71 (MCC) • MI: 410.x (MCC)—look for EKG changes, heparin, elevated troponin level—if admitted to r/o MI, document if patient had acute MI Joy King Consulting, LLC

12. Acute MI • New universal definition: Myonecrosis • Elevation of troponin > 99th percentile of normal • MI=”myonecrosis secondary to ischemia” • MI = myonecrosis + at least 1 below: • Symptoms • Ischemic ST or T wave changes • New LBBB • New Q waves • PCI-related marker elevation or + imaging for new myocardial loss Joy King Consulting, LLC

13. MI Complications Cardiogenic shock V tach Bilateral BBB coronary dissection Trifascicular block respiratory failure PAT cardiac arrest Pericarditis V flutter/fib Accelerated HTN pulmonary embolus 2nd degree Mobitz I block 3rd degree AV block other arrhythmias Joy King Consulting, LLC

14. Arrhythmias • A fib 427.31 – not a CC • A flutter 427.32 – CC: rapid rhythm w/ heart rate > 100; if > 120, palpitations, dizziness, syncope • A fib/flutter—use both codes • V tach 427.1 (> 100/min) – CC: abnormal rapid heart beat w/ heart rate > 120; if sustained, heart failure may follow Code if sustained—not tx if < 30 seconds Joy King Consulting, LLC

15. Arrhythmias • V fib 427.41 – MCC only if patient d/c alive: rapid irregular rhythm, usually caused by severe myocardial damage or drug toxicity; heart pumps little or no blood & death w/in minutes if tx not immediate • V flutter 427.42 – MCC: Tx w/ cardioversion/AICD, IV lidocaine & beta blocker; Amiodarone may be used to suppress V tach or V fib Joy King Consulting, LLC

16. Heart Blocks • 426.6 SA block—not a CC • 426.10 unspec AV & 426.11 1st degree AV—not CCs • 416.12—2nd degree Mobitz II – CC • 416.13—2nd degree Mobitz I or Wenckebach’s—not a CC—rarely tx • 426.0—3rd degree complete – CC • LBBB—not CCs • RBBB—only 426.53 bifascicular & 426.54 trifascicular are CCs Joy King Consulting, LLC

17. Complete AV Block • S/S: lethargy, postural HTN, SOB, syncope, dizziness—usually results from infection, fibrosis, or scarring from MI, digitalis toxicity • Tx: w/ inferior MI—tx w/ temporary pacer; w/ anterior MI—treated w/ permanent pacer Joy King Consulting, LLC

18. Chest Pain MS-DRG Options • DRG 313 Chest Pain (no split) 0.5314 • DRG 303 Atheroscl w/o MCC 0.5688 • DRG 311 Angina (no split) 0.4972 • DRG 282 Acute MI, alive w/o CC 0.8696 • DRG 204 Resp S/S (no split) 0.6548 • DRG 392 Esophagitis, GE w/o MC 0.6703 • DRG 395 Other digestive w/o CC 0.6765 • DRG 446 Dx biliary tract w/o CC 0.7231 • DRG 74 Cranial/periph nerve 0.8423 Joy King Consulting, LLC

19. Decubitus Ulcers • S/S: bed-ridden, paralysis, necrosis, hx injury in DM, pressure sores, edema, blisters, osteomyelitis, induration, cellulitis • Tx: wound care orders, air bed, debridement, frequent turning Joy King Consulting, LLC

20. Decubitus Ulcers • Stage 1: non-blanching erythema (reddened area on skin) • Stage 2: abrasion, blister, shallow open crater, or other partial thickness skin loss • Stage 3: full-thickness skin loss involving damage or necrosis into subcutaneous soft tissues • Stage 4: Full-thickness skin loss w/ necrosis of soft tissues through to the muscle, tendons, or tissues around underlying bone. • Unstageable: due to being inaccessible for evaluation (non-removable dressings, eschar, sterile blister, suspected deep injury in evolution). (Included in CC 4 Q 2008) Joy King Consulting, LLC

21. Coding Pressure Ulcers • 2 Codes required: 707.0x for site/diagnosis + 707.2x for stage. (Stage codes 707.23 & 707.24 are MCCs) • The 707.2x code for stage should follow the 707.0x code for diagnosis/site • Don’t confuse 707.25 “unstageable” (clinical assessment) with 707.20 “stage unspecified” (documentation issue) • If the pressure ulcer progresses during the stay, code to the highest stage Joy King Consulting, LLC

22. Pressure Ulcer Stages • Diagnosis of pressure ulcer & site must be documented by an MD to be coded—can’t just document “wound” • The stage of the pressure ulcer can be coded from clinicians involved in the care of the ulcer (Wound Care RN) • If a pressure ulcer is documented as Stage 2 on admission, but progresses to Stage 3 or 4 during the stay, the code for highest stage should be listed on the claim • The POA indicator for the ulcer should be Y even if the stage has progressed during stay** Joy King Consulting, LLC

23. Sequencing Stage Codes • Encoders generally sequence the codes to pull those impacting reimbursement (MCC/CCs) into the top 9 read by CMS • The stage codes are to be sequenced after the diagnosis/site codes; however they impact reimbursement if Stage 3 or 4 • The coders may have to manually resequence those within the top 9 before codes drop to the bill (may have encoder setting to do it) • Develop a policy to clarify if that will be done for all Stage 3 or 4 pressure ulcers, especially if other MCCs w/ + impact can fill up top 9 Joy King Consulting, LLC

24. GI Disorders CC MCC Joy King Consulting, LLC Diverticulitis Gastric Ulcer Blood in Stool GI Hemorrhage Diverticulitis w/ hemorrhage Diverticulosis w/ hemorrhage Gastritis w/ hemorrhage

25. Impact on Severity/Reimbursement Adm for COPD exacerbation w/ acute bronchitis. Stools occult +; EGD confirmed gastritis. PDx: COPD exacerbation, Secondary Dx: Gastritis MS DRG 192 COPD w/o CC/MCC r.w. 0.7254 $3718 Secondary Dx: Gastritis, GI bleed MS DRG 191 COPD w/ CC r.w. 0.9757 $5000 +($1,282) Secondary Dx: GI bleed due to gastritis MS DRG 190 COPD w/ MCC r.w. 1.3030 $6678 +($2960) Joy King Consulting, LLC

26. Degree of Malnutritionwww.merck.com Joy King Consulting, LLC

27. Malnutrition • 263.0 Moderate malnutrition—not a CC • 263.1 Mild malnutrition—not a CC • 263.8—Other protein-calorie malnutrition—CC • 263.9—Unspecified protein-calorie Malnutrition—CC • 263.2—Arrested developmt following malnutrition—CC • 260—Kwashiorkor—MCC: wet, swollen, edematous form • 261—Marasmus (severe malnutrition)—MCC: dry form, causes wt loss & depletion of fat • 262—Other severe malnutrition—MCC: any disorder protein-calorie nutrition other than marasmus • 799.4—Cachexia (BMI < 18.5)--CC Joy King Consulting, LLC

28. Nutritional Status CC MCC Joy King Consulting, LLC Protein-Calorie Malnutrition Malnutrition Cachexia BMI <19, >39 Severe Malnutrition Severe Protein (Calorie) Malnutrition

29. Malnutrition Scenario • Pneumonia (486) Principal Diagnosis • Protein-calorie Malnutrition, unspecified (263.9) documented as secondary dx (CC) • Query for severity of Malnutrition per documentation of Albumin levels of 2.1 and 2.4, which can be indicative of “Severe Malnutrition” (MCC) Pneumonia w/ CC DRG 194, 1.0056 $5,704 Pneumonia w/ MCC DRG 193, 1.43270 $8,127 Joy King Consulting, LLC

30. Impact on Severity/Reimbursement PDx: Chronic Osteomyelitis Leg Secondary Dx: Malnutrition (CC) MS DRG 539 r.w. 2.0287 $6,905 Secondary Dx: Severe Malnutrition (MCC) MS DRG 540 r.w. 4.5059 $ 10,357 Difference of $3,452 Joy King Consulting, LLC

31. Impact on Severity/Reimbursement PDx: CA colon Secondary Dx: Malnutrition Procedure: Bowel resection MS DRG 330 Major Bowel Proced w/ CC r.w. 2.5589 $14,074 Secondary Dx: Severe malnutrition MS DRG 329 Major Bowel Proced w/ MCC r.w. 5.1666 $28,416 +$14,342 Joy King Consulting, LLC

32. Electrolyte Imbalances • Hyponatremia (276.1)—CC: caused by CHF, cirrhosis, ARF, SIADH, Addison’s, hypothyroidism, diuretic, hypoaldosteronism • Hyperkalemia (276.7)—not a CC; caused by acute/chr kidney failure, metabolic acidosis, hypoaldosteronism Complications of electrolyte imbalances include metabolic encephalopathy, seizures, V tach Joy King Consulting, LLC

33. Hyponatremia • S/S mainly from CNS dysfunction: • Headache • Confusion • Stupor • Can lead to seizures, coma & death Joy King Consulting, LLC

34. Altered Mental Status • In elderly, often the only symptom of infection such as UTI, pneumonia or sepsis on presentation • Delirium, stupor, coma, mania, confusion, psychosis, delusions, depressive features, hallucinations are CC’s and show severity • Alzheimer’s is MCC if document delusional, depressed or psychotic features • Dementia—document cause/type • Schizophrenia—CC • Drug withdrawal—CC Joy King Consulting, LLC

35. Metabolic Encephalopathy • Synonyms: Delirium (780.09—not CC) or Acute Confusional State (code 293.0 for “acute” delirium & acute confusional state) -- CCs • Encephalopathy Codes 348.30 – 348.39 – MCCs • Common Causes: drugs, dehydration, infection • Metabolic encephalopathy (348.31) due to metabolic issues from underlying cause; seen in 12-33% of patients w/ organ failure • Toxic encephalopathy (349.82) – MCC, due to drugs, usually denotes altered state of consciousness such as delirium Joy King Consulting, LLC

36. Delirium • Acute changes in cognition fluctuating during the day • Inattention plus • Disturbance of consciousness (less clarity) or • Altered level of consciousness or disorganized thinking • Unlike delirium, mental disorders (dementia, etc.) almost never cause inattention or fluctuating consciousness Joy King Consulting, LLC

37. Delirium • 10% of elderly admitted to hospital w/ delirium—15-50% experience delirium at some point during the hospital stay • Tx: correction of cause—abx for infection, IV fluids & electrolytes for dehydration, etc. • Morbidity/mortality higher in patients w/ delirium when hospitalized or who develop it during stay—1 yr mortality of 35-40% (same as AMI & sepsis) Joy King Consulting, LLC

38. Scenario Pt adm w/ AMS & delirium—not on diuretics. Na of 118, tx w/ hypertonic saline & sent home on fluid restriction. Final Dx: Delirium due to Hyponatremia DRG Options: 276.1 Hypo Na DRG 641 w/o MCC 0.6820 780.09 Delirium DRG 81 0.7104 253.6 SIADH DRG 645 w/o CC 0.7188 348.30 Met encephal DRG 71 w/ CC 1.1361 253.6 + 348.30 DRG 643 w/ MCC 1.6464 Joy King Consulting, LLC

39. Reflection of Severity Joy King Consulting, LLC • Closed head injury • poorly controlled DM • Anemia • Angina • Na = 125 • Respiratory insufficiency Concussion or loss of consciousness DM, uncontrolled Type of anemia Type of angina Hyponatremia Respiratory failure

40. Potential Severity Queries • BS > 100, 200, 500, Hgb A1c > 7.0—uncontrolled DM? • CO2 of 15—query for acidosis • ABGs w/ pH 7.32, CO2 50, PO2 60 (50/50 or 50/60 club) non-rebreather mask or BiPAP, CPAP—query for resp acidosis if not on vent • Albumin < 3.0 for 3 wks, prealbumin < 16, BMI < 17—query for severe malnutrition • BMI > 35, > 40 w/ DM or CAD—metabolic syndrome • Elev troponin, EKG changes, on heparin, seen by Cardiology—query for MI • Platelets around 100,000—query for thrombocytopenia • Elev BS, on steroids and SSI—hyperglycemia or DM secondary to steroids • Chronic drug use—query for dependence • Chronic O2 use—query for dependence Joy King Consulting, LLC

41. Documentation Improvement Tips • Use Nurses notes, Wound care notes, PT, OT, ST, Nutritional notes to generate information for queries • Ask Nursing to capture diagnoses when documenting verbal orders • Ask Wound Care nurse to identify type, location, Stage of decubitus and other wounds in the orders co-signed by the MD and/or have the MD co-sign Wound Care progress notes • Ask Nutrition to identify stage of malnutrition as basis for queries and/or have them document BMI values NOTE: BMI values can be coded from Nutrition notes w/o MD documentation (exception per AHA) Joy King Consulting, LLC

42. Physician Queries When: • There are specific clinical indications that indicate the condition may be present • Documentation from different MDs conflicts—clarification should be obtained from attending MD • Not needed when a consultant/anesthesiologist documents additional dx or specificity from attending • Diagnosis not mentioned after the 1st day or two and/or treatment not consistent w/ that diagnosis, e.g. abx discontinued • Unable to tell if a condition was POA Joy King Consulting, LLC

43. Physician Queries How: • Develop policy guidelines on when to query • Document specific clinical evidence from the record, including ancillary findings, tx, etc. to support the query • Keep questions open-ended, rather than yes or no * • Leading questions—not based on clinical clues in record, no reason to ask the question • Have MD document information in the PN and/or DS if the query form will not remain in the record Joy King Consulting, LLC

44. How to Query • The process for querying physicians must be a patient-specific process, not a general process. • Each facility should develop a standard format for the query form. No ‘sticky notes’ or scratch paper should be allowed. • Preferred formats: facility-approved query form, fax, secure email, secure IT messaging system, verbal queries Joy King Consulting, LLC

45. How to Query • Multiple choices w/ checkboxes OK if ALL clinically reasonable choices listed, regardless of financial impact. • Should include an “other” option w/ line for MD to write in • Should include an “unable to determine” option. Joy King Consulting, LLC

46. How to Query • If there are multiple questions for one case, ensure that: • It is clear to the physician that he/she has more than one to respond to and • Ensure that there is sufficient room to write a response (if it is required on the form) • E.g. IDDM w/ elevated BS documented on admission in patient w/ renal failure • Q 1: type of DM • Q 2: relationship of DM to renal failure • Q 3: DM uncontrolled or controlled? Joy King Consulting, LLC

47. Physician Queries • # queries WILL increase--may impact # DS • Document response to queries either in PN/DS or on a query form that remains in the MR • POA query forms can utilize a checkbox format which MD initials or signs • The MD query will NOT include a U option, only a W for “clinically undetermined” • Hold claims w/ outstanding POA queries for response, since this is a billing requirement—will impact DNFB Joy King Consulting, LLC

48. Pneumonia vs. AMI Scenario • H&P, Admit order state “R/O Pneumonia • CXR neg for infiltrate, no elev WBC • Elevated troponin levels & cardiac enzymes, abnormal EKG, transferred to larger facility on 1st day of stay • No DS on chart, no progress notes • Case coded to Pneumonia (486) as Principal Diagnosis based on H&P & Admit Order • Query? Pneumonia DRG 195, 0.7316 $4,150 AMI DRG 282, 0.8696 $4,933 Joy King Consulting, LLC

49. Acute Renal Failure Scenario • Patient presented with altered mental status, BUN 169, Cr 4.8, Na 172. PN 10/19 states, “admitted with dehydration, azotemia & hyponatremia.” The DS states patient treated w/ IV fluids, azotemia resolved, still stuporous. • Hyponatremia (276.1) coded as Principal Diagnosis • Query? Hyponatremia DRG 641, 0.6820 $3,869 Acute Renal Failure DRG 683, 1.1304 $6,412 Joy King Consulting, LLC

50. AMS Scenario NH patient presents to ED w/ 2-day hx decreased oral intake & AMS. CXR shows no infiltrates. WBC 15,000, Na 118, U/A spec gravity of 1.030, BUN 58, Cr 1.4. Admitting dx is AMS & renal insufficiency. No further mention of renal status in chart. Patient tx w/ IV fluids and IV abx. DS lists Pneumonia & Dehydration. Query? Joy King Consulting, LLC