Knowledge Base Category -

Background

As part of the Deficit Reduction Act of 2005 (DRA), hospitals were required to begin reporting whether or not diagnoses were Present on Admission (POA) on or after October 1, 2007.

General POA Requirements:

• POA indicator is required for all claims involving Medicare inpatients admitted to general IPPS acute care hospitals.
• POA is defined as present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA.
• The POA indicator is assigned to the principal diagnosis and secondary diagnoses.
• Inconsistent, missing, conflicting or unclear documentation must be resolved by the provider.
• POA indicator is not reported if a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current Official Guidelines.
• CMS does not require a POA indicator for the external cause of injury code unless it is being reported as an “other diagnosis.”

(Source: CMS POA Fact Sheet)

Office of Inspector General (OIG) November 23, 2012 Report: Assessment of Hospital Reporting of Present on Admission Indicators on Medicare Claims.OEI-06-09-00310

The OIG recently released a report that assessed POA indicator accuracy and the nature of any miscoding. As background to this review the OIG indicated that Section 5001 (c) of the Deficit Reduction Act of 2006 mandated that hospitals would not receive increased Medicare reimbursement for certain conditions that develop during a hospitals stay that were not present on admission. These conditions are referred to as “hospital-acquired conditions” and the list of conditions is updated annually. Assigning POA indicators “provides a necessary framework” for making the determination of whether or not a diagnosis is a “hospital-acquired condition.”

For the report, the OIG utilized contracted certified coders that reviewed medical records and “documented all misreported POA indicators and described circumstances that may have contributed to the errors.”

The OIG found that “hospital coders incorrectly reported 3 percent of the 5,491 POA indicators reviewed, resulting in the presence of at least one incorrect indicator on 129 claims (18 percent).” There were three main groups of errors identified and include:

• Twenty-One Percent were related to the assessment of developing or chronic conditions
• Conditions that were developing at the time of admission with misreported POA indicators included systemic inflammatory response syndrome (SIRS), septic shock, blood infections, urinary tract infections, pneumonia, pressure ulcers, constipation, and malnutrition.
• Chronic conditions with misreported POA indicators included diabetes and patient’s experiencing an exacerbation of a chronic condition such as congestive heart failure.

• Thirty-Two Percent involved errors in assigning POA indicators to exempted conditions.
• In these cases the hospital coder either assigned a POA indicator code when he/she should have identified the diagnosis as exempt or coded a diagnosis as exempt when it was not on the published list of exemptions and should have been assigned POA indicators.

• Forty-Seven Percent involved other reporting errors not associated with developing or chronic conditions or with exemptions. Specific examples in the report include:

• The OIG coders found documentation contradicting the POA designation.
• Medical record review clearly indicated the presence or absence of a diagnosis at the time of admission. “This suggests that hospital coders may have failed to notice or disregarded the information necessary to make an accurate POA assessment.”
• Physician’s documentation not clearly indicating when a condition developed.
• Other issues such as a diagnosis changing during the hospitalization.

 

The OIG concluded that the 3-percent error rate is relatively low and no recommendations were made. At MMP we believe that it is important to point out that in their conclusion, the OIG indicates that “POA indicators provide an opportunity for monitoring hospital quality of care and are critical to CMS’s efforts to link payment to quality, but they must be accurate to serve these purposes. Encouraging hospitals to assess POA reporting practices related to developing conditions and exemption codes, and to retrain staff as needed, could help to ensure accuracy.”

 

When talking to hospital staff and Physicians about high resource consumption, high readmission rates and high mortality rates, one explanation you almost always hear is “my patients are sicker.”

But how do you know if your patients are sicker? Understanding your facility’s Case Mix Index (CMI) is a good way to answer this question. However, to understand CMI you need to first understand the basic fundamentals of the Inpatient Prospective Payment System (IPPS) and how a Coder in a hospital determines the Diagnosis-Related Group (DRG) assignment for every hospital inpatient stay.

Background:

In 1983, Congress mandated the Inpatient Prospective Payment System (IPPS) for all Medicare inpatients. IPPS uses Diagnosis-Related Groups (DRGs) to determine reimbursement for hospitals.

Beginning October 1, 2007 the DRG system began transitioning to a new system called Medicare Severity MS-DRG. The transition to MS-DRGs allowed for an improved accounting of a hospital’s resource consumption for a patient and the patient’s severity of illness.

Assigning a DRG:

Principal Diagnosis:

The Uniform Hospital Discharge Data Set (UHDDS) defines the Principal Diagnosis as “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

Comorbidities and Complications (CCs and MCCs):

These are conditions that increase a patient’s resource consumption and may cause an increase in length of stay compared to a patient admitted for the same condition without a co-morbidity or complication. When the DRG system transitioned to MS-DRGs the comorbidites and complications were divided into three levels. The three levels are DRGs without a CC or MCC, DRGs with a CC and DRGs with a MCC.

• Comorbidities are the conditions that patients “bring with them” when they are admitted to a hospital and continue to require some type of treatment or monitoring while in the inpatient setting. For example:
• A patient with a history of atrial fibrillation is continued on his home medications and placed on telemetry monitoring.
• A patient with a history of Diabetes is placed on pattern blood sugars with sliding scale insulin
• A patient has a history of hypercholesterolemia and is continued on their home Statin therapy.
• Complications are those conditions that occur during the inpatient hospitalization. For example:
• A patient undergoes hip surgery and experiences acute post-op blood loss anemia in the peri-operative period requiring serial Hemoglobin and Hematocrit checks and possibly blood transfusions.
• A patient with a history of chronic obstructive pulmonary disease undergoes surgery and develops post-op respiratory failure.

• Major Comorbidities and complications (MCCs): DRGs with MCCs reflect the highest level of severity. For example:
• A patient with chronic systolic heart failure is admitted for a GI bleed, becomes volume overloaded and develops acute on chronic systolic heart failure during the admission.

As many times as we have heard it said it remains true, if you don’t document it then it wasn’t done or in the case of DRG assignment it wasn’t present and treated during the hospitalization. A Coder’s ability to code to the most appropriate DRG is dependent upon the Physician documentation in the medical record. Coding Guidelines do not allow coders to interpret lab findings, radiology findings, EKGs or pathology reports to assign diagnosis codes.

A successful DRG program in a hospital is dependent on the Physician providing a complete accounting of a patient’s Principal Diagnosis, comorbidities and complications, any procedures performed, the plan of care and the patient’s discharge status.

Example:

A patient presents with chest pain and has a known history of GERD. A Myocardial Infarction (MI) was ruled out based on EKG and Cardiac Enzymes and the patient was discharged home with a new prescription for Prilosec. In this case chest pain is a symptom code and a more specific diagnosis would be chest pain related to GERD. However, if the only diagnosis written by the Physician in the record is chest pain then the coder can only assign the code for unspecified chest pain.

This is why Coders and in more recent years Clinical Documentation Specialist send queries to Physicians. As far back as 2007, CMS has indicated 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.” (Source: Federal Register / Vol. 72, No. 162 / Wednesday, August 22, 2007 / Rules and Regulations – page 47180)

Diagnosis-Related Group (DRG) is a diagnosis classification that groups patients that have a similar resource consumption and length-of-stay.

Relative Weight (RW) is a numeric weight assigned to each DRG that is indicative of the relative resource consumption associated with that DRG. For CMS fiscal year 2011 (October 1, 2010 through September 30, 2011) relative weights range from as high as DRG 001: Heart Transplant or Implant of Heart Assist System with MCC at 26.3441 to as low as DRG 795: Normal Newborn at 0.2284. Medical DRGs (e.g. chest pain, pneumonia, congestive heart failure) will have a lower relative weight than surgical DRGs.

Case Mix Index (CMI): The Ingenix 2011 DRG Expert defines CMI as “the sum of all DRG relative weights, divided by the number of Medicare cases. A low CMI may denote DRG assignments that do not adequately reflect the resources used to treat Medicare patients.”

An easier way to explain CMI is to compare it to a student’s Grade Point Average (GPA). A higher GPA is reflective of a student’s academic success. Likewise, a higher CMI for a hospital is reflective of a successful DRG program.

GPA Example:

(A=4 grade points / B=3 grade points / C=2 grade points / D = 1 grade point / F = 0 grade points)

 

Formula for GPA: Total Grade Points ÷ Sum of Credit Hours = GPA

21 ÷ 10 = 2.10 GPA

 

Case Mix Index Example A:

 

Formula for Case Mix Index:

Sum of Relative Weights ÷ Total Number of DRGs Coded = Case Mix Index

Example A Case Mix Index: 3.7543 ÷ 4 = 0.9386 Case Mix Index

 

Example B: The Potential Impact Physician Queries can have on DRG Assignment:

 

1. Example B Case Mix Index: 4.9944 ÷ 4 = 1.2036 Case Mix Index

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“The higher the case mix index, the more complex the patient population and the higher the required level of resources utilized. Since severity is such an essential component of MS-DRG assignment and case mix index calculation, documentation and code assignment to the highest degree of accuracy and specificity is of utmost importance.”

(Source: Ingenix 2011 DRG Expert)

 

Challenges for Hospitals:

 

Understanding what can make your hospitals CMI fluctuate?

• A decrease in CMI may be reflective of:
• Non-specific documentation by the Physician
• Increase in Medical Volume with a decrease in Surgical Volume as Surgical DRGs have a higher Relative Weight.
• Surgeons being on vacation
• Physicians being unresponsive to Coder and Clinical Documentation Specialist queries
• An increase in CMI may be reflective of:
• Tracheostomy procedures that have an extremely high Relative Weight
• Ventilator patients
• Open Heart Procedures
• Improved Physician Documentation
• Improved Physician response rate to queries resulting in an improved CC / MCC capture rate

Realizing the Importance of every Medical Professional’s role in the success of a hospital’s DRG program:

 

• The Physician’s Role: Is to provide complete and accurate documentation of a patient’s Principal Diagnosis, comorbidities and complications, any procedures performed, the plan of care and the patient’s discharge status in the medical record.

 

• The Clinical Documentation Specialist’s Role: Is to perform concurrent medical record reviews and ask queries whether verbal or written when indicated.

 

• The Coder’s Role: May be concurrent medical record review or a retrospective review after discharge; also ask queries when indicated.

 

The American Health Information Management Association (AHIMA) published a practice brief “Managing an Effective Query Process” in October 2008. The AHIMA brief states that “Providers should be queried whenever there is conflicting, ambiguous, or incomplete information in the health record regarding any significant reportable condition or procedure” or if “additional information is needed for correct assignment of the POA indicator.”

 

Further, AHIMA suggests querying when documentation in the patient’s record fails to meet one of the following five criteria:

• Legibility
• Completeness (e.g. abnormal test results without notation of clinical significance)
• Clarity (e.g. diagnosis without statement of cause or suspected cause)
• Consistency (e.g. conflicting documentation)
• Precision (e.g. greater specificity)

The entire brief can be found at AHIMA's Managing an Effective Query Process.

 

So, how do you know if your patients are sicker?

 

Internally, hospitals can:

• Work with their Decision Support staff to develop CMI reports by facility and by individual physicians.
• Perform root-cause-analysis when you see fluctuations in the CMI rate.
• Use CMI reports to compare Physicians in like specialties to each other.

External Resource for hospitals:

MMP, Inc’s sister company RealTime Medical Data (RTMD) affords hospitals the unique ability to finally compare their CMI rates to other hospitals within their defined market as well as statewide. RTMD uses real Medicare paid claims data and reports are based on the total market – all residents, all physicians, and all hospitals within Alabama, Mississippi, Tennessee, Georgia, Florida, Louisiana, Arkansas, Delaware, District of Columbia, Maryland, New Jersey, North Carolina, Oklahoma, Pennsylvania, South Carolina and Texas.

 

RTMD reports that can help a hospital and physician’s answer this question include:

• CMI Detail Reports
• Provider CMI Details by DRG with Statewide CMI: This report represents CMI for the Provider with DRG details and includes Statewide CMI for all providers.
• Provider CMI Details by Physician: This report represents CMI for the Provider with Physician Details.

 

A successful DRG program is dependent on accurate documentation. Addressing issues that can impact CMI will enable you to capture the most accurate severity of illness, have a positive impact on reimbursement and support the medical necessity of inpatient admissions.

 

CMS’s Medicare Learning Network publishes quarterly Medicare Compliance Newsletters to address the findings from reviews by Medicare contractors such as MACs, RAs (formerly RACs), ZPICs, CERT and the OIG. A cursory look at the October 2012 newsletter might lead you to believe it is the same old issues with the same old information. But a more thorough reading of the details reveals education and guidance on coding / billing issues and examples of services provided in an inappropriate level of care. And of course the usual information is there also – but in these days of seemingly never-ending recoupment, one more reminder doesn’t hurt.

Coding Issues

Inappropriate secondary diagnosis with major joint replacements that resulted in inappropriate DRG assignment:

• “Moderate protein nutrition” should only be assigned code 263.0, Malnutrition of moderate degree, because this code category includes protein-calorie malnutrition. Code 260, Kwashiorkor, is not appropriate since this condition was not specifically documented. (Coding Clinic: Third Quarter, 2009)
• Code 416.2 was created in October 2009 to describe chronic pulmonary embolism to distinguish these from acute pulmonary emboli. Use this code if the patient did not have an acute PE during the current admission, instead of reporting code 415.19. (Coding Clinic, Fourth Quarter, 2009)

Sequencing errors related to the principal diagnosis with cardiac procedures that resulted in inappropriate DRG assignment.

• Code acute myocardial infarction (410.xx) as the principal diagnosis rather than CAD (414.01) for patients who present with an acute MI and are successfully treated with angioplasty. (Coding Clinic, 4th Quarter 2005 and Coding Clinic, 2nd Quarter, 2001)

Billing Issues

Outpatient within Inpatient Stay

• A separate claim for laboratory services by the same hospital during the time frame of an inpatient admission.
• A separate claim by another hospital for ERCP services during an inpatient admission. If an outside entity provides services to an inpatient, those services are part of the inpatient admission. The inpatient hospital should make arrangements with the outside entity to ensure that a separate outpatient claim is not submitted to Medicare.

Inappropriate Hospital Admissions

Respiratory Conditions

• Patient with mild COPD 2 and costochondritis who presented with chest pain and successfully treated with IV ketorolac; discharged next day. Per Medicare reviewers, services should have been provided at outpatient level of care.
• Patient with wheezing and hypoxemia post EGD; successfully treated with IV Solu-Medrol and IV Protonix and discharged home the next day. Per Medicare reviewers, services should have been provided at outpatient level of care.

DRG 581, Other Skin, Subcutaneous Tissue and Breast Procedures

• Two examples of uncomplicated mastectomies, discharged home the next day. Per Medicare reviewers, services should have been provided at outpatient level of care.

Please read the October 2012 Medicare Quarterly Compliance Newsletter to see the complete examples and other helpful information.

Medicare Hospital Dialysis Services 

CMS Transmittal 2455 released April 26, 2012 informs hospitals about the correct billing of acute dialysis services for Medicare inpatients and outpatients.

HCPCS code G0257 is only to be billed for hospital outpatients with ESRD. G0257 is not to be reported for hospital inpatient services billed under Part B (12x type of bill) or for hospital outpatients who do not have ESRD. HCPCS code G0257 is used for hospital outpatients with ESRD when the criteria listed below from the Medicare Claims Processing Manual, chapter 4, section 200.2 is met.

“Payment for unscheduled dialysis furnished to ESRD outpatients and paid under the OPPS is limited to the following circumstances:

• Dialysis performed following or in connection with a dialysis-related procedure such as vascular access procedure or blood transfusions;
• Dialysis performed following treatment for an unrelated medical emergency; e.g., if a patient goes to the emergency room for chest pains and misses a regularly scheduled dialysis treatment that cannot be rescheduled, CMS allows the hospital to provide and bill Medicare for the dialysis treatment; or
• Emergency dialysis for ESRD patients who would otherwise have to be admitted as inpatients in order for the hospital to receive payment.”

HCPCS code G0257 may only be reported on Type of Bill (TOB) 13X (hospital outpatient service) or TOB 85X (Critical Access Hospital). Effective for services on and after October 1, 2012, claims containing HCPCS code G0257 will be returned to the provider for correction if G0257 is reported with a type of bill other than 13X or 85X (such as a 12x inpatient claim).

Hospitals should report HCPCS code 90935 (Hemodialysis procedure with single physician evaluation) for the following hospital dialysis services.

• Hospital inpatients with or without ESRD who have no coverage under Part A, but have Part B coverage. The service must be reported on a Type of Bill 12X or Type of Bill 85X.
• Hospital outpatients who do not have ESRD and are receiving hemodialysis in the hospital outpatient department. The service is reported on a TOB 13X or l 85X.

CPT code 90945 (Dialysis procedure other than hemodialysis (e.g. peritoneal dialysis, hemofiltration, or other continuous replacement therapies)), with single physician evaluation, may be reported by a hospital paid under the OPPS or CAH method I or method II on type of bill 12X, 13X or 85X.

For complete information see the transmittal at the link above or the MLN Matters Article MM7732.