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For other articles and previous issues click here. September 12, 2005 Please,
Not the “F” Word Of course, we’re speaking of fraud, the expletive no upstanding coding department wants to hear. Whether you prefer to call it creative coding, fiscal reconsideration, or some other euphemism, fraud still has only one effect. The pressure is on the hospital’s coding department from all types of areas and for several different issues. Responsible facilities never intend to induce their coding staff to commit … well, you know what. However, they may, through misdirected intent or just plain ignorance of the law, end up doing exactly that. Consider some of the following scenarios. What about the payor who requires emergency conditions to cover medical treatment? An example may be the emergency department patient with a chief complaint of chest pain. After study, however, the cause is determined to be gastroenteritis or even anxiety. The final diagnosis may not meet the carrier’s definition of an emergency condition. It may toss the whole claim to a psychiatric coverage issue since the code for anxiety is from the code chapter on mental disorders. It’s quite possible that a well-intentioned party will be contacting the coding staff demanding a “better code” so they can get paid, despite the fact that the case is already coded correctly. Third-party payors may have their own issues with correct coding in cases such as the one outlined above. Software systems on the insurance side may only recognize the first diagnosis code and will approve or deny payment based on that alone. If the diagnosis requires a pair of codes, it could be the second half of the pair that qualifies as the emergency condition. The payor may even request that the facility resequence the codes to pay the claim correctly. What does that do to the correct reporting, case mix, hospital statistics, and all the other data streams that support our healthcare and financial decisions? It’s easy enough to say one should code everything the same for the sake of purity. Can it be correct to code, as it were, incorrectly so correct reimbursement is made? You may begin to see why coders believe migraine headaches should be covered by workers’ compensation. Then we have the Vcode issue. It is surprising how many people firmly believe that Vcodes are not allowed as principal diagnoses. However, your coding staff may not be in error for its use: The code may be correct, but Medicare won’t pay an inpatient claim for that problem. System edits may warn the coder of the nonpayment issue, putting on the squeeze to find a different code that still seems reasonable but has no edits. Education is a primary factor for this scenario—the coders must be aware of correct rules for use of Vcodes and the medical staff must be on board for documentation and medical necessity issues. Coder education is also critical to prevent inadvertent incorrect billing. Pregnancy, HIV, poisonings, abuse, and other diagnoses have their own sets of rules that may decrease diagnosis-related group (DRG) payment drastically instead of grouping to the higher DRG for the same diagnosis when it’s not caused by one of these conditions. Conflicting coding rules for the patient who gets admitted with the chronic renal failure-congestive heart failure-volume overload-pulmonary edema complex can give chest pain to even the most seasoned coder. Rules change as often as AHA Coding Clinic for ICD-9-CM and CPT Assistant can be published, and coverage can change with each Medicaid or Medicare bulletin. There’s even more pressure to get those charts coded while maintaining your continuing education. In other words, hurry up, but don’t make any mistakes. Not all pressures arise from financial concerns, although the problem may affect payment as well. Coders can be approached for internal issues involving complication codes that—while coded correctly as documented in the chart—may raise concerns that the facility could be perceived as making errors in treatment. More education may be needed for the noncoding staff. These codes may only indicate that the patient had an abnormal response (or even a common, expected one) to a particular procedure or medication. They don’t automatically indicate wrongdoing or poor medical treatment and must be coded and reported for accurate national tracking and development of better outcomes. To not report them could later be construed as suppression of facts. An example of this kind of issue is the documentation of a diagnosis of blood loss anemia on postsurgical patients and maternity cases. Surgeons are loath to document what looks like a failure to manage their patient, especially when the procedure itself is commonly associated with significant blood loss. Coders are directed, however, to code only the blood loss anemia without the additional code for hemorrhage complicating a procedure, unless the physician documents it specifically as a complication. Cesarean sections typically result in a blood loss in the neighborhood of 1,000 cubic centimeters so the doctor will view this as “expected” and may not consider that it is still being clinically evaluated with labs and medical decision making. The patient is likely to be treated at least with iron supplement, whether or not they also require transfusion. The coder is expected to query the physician to make sure there are diagnoses associated with labs and symptoms because both cases affect the DRG and final payment. As you may have guessed, this can be met with varied responses. While some physicians will explain why the diagnosis of anemia is not appropriate, or document that it really is anemia, not all are so pleasant. The coder may be dismissed with, “Of course it’s blood loss anemia, I documented the labs and you should know that.” The doctor may be annoyed or even angry and refuse to be told how to document by someone they don’t perceive as a clinical specialist. There’s pressure, and then there’s pressure, and the query task is not for the weak of heart. Even the decision of whether to query is piled onto the coder’s shoulders. Coding Clinic repeatedly states that if the relationship between the documentation and the rules is unclear, it’s the burden of the coder to decide whether the physician must be queried. Ultimately, if the coder believed the documentation was sufficient but later review by the Office of the Inspector General disagrees … well, you-know-who will be accused of you-know-what. It’s quite a responsibility when even the reviewer with a medical degree who tended to the patient cannot always pin down cause and effect, or even a yes or no for some diagnoses. Should the coding staff ever become immune to the pressures to maximize reimbursement at the cost of accurate and specific coding, they still have another mammoth force with which to contend. For every person who wants to lean to the left in coding a patient encounter, there’s going to be a payor that’s going to shove back to the right. Consider the auditors who perform retroactive reviews on the hospital’s charts. How many times has a reviewer refused to pay a claim that is coded correctly, and billed with the correct DRG, because the patient’s length of stay didn’t match that for the DRG? How common is it for the text of a DRG to be considered by an auditor to be the determining factor in whether the requested payment will be made? These can be honest errors made in ignorance of the Centers for Medicare & Medicaid Services (CMS) coding rules and the workings of a valid DRG grouper. It’s easy to understand why someone may question “newborn with major problems” as a DRG for a baby whose nuchal cord-induced hypovolemia increases payment by thousands of dollars, but only took minutes to treat, and resolved rapidly. The facility must stick to its guns, however, and demand correct payment for correct coding. If CMS coding guidelines are followed and documentation is clear and valid, then the DRG to which the case groups is also correct whether or not it “looks” right. All too often it is considered easier to not antagonize a major reimbursement force. It certainly is a battle to educate the other side, but it can—and must—be done to ensure continued correct payment to the facility. Don’t allow the payor to demand incorrect coding from your staff any more than you’d permit it from within. Think, too, of the utilization review personnel on the payor side who may approve a DRG in advance of billing based on clinical information from the facility’s corresponding staff. How many of these are nurses without any coder training? What many administrators and even clinical professionals fail to realize is that DRG payment is not based on the clinical severity of any single patient. Rather, it is based on the average cost of treating that type of patient. Coding and sequencing rules are incredibly complex and specific. When the clinical information doesn’t match the final DRG, the ball drops right in the coders’ court. Why didn’t they code it right? After all, nurses and doctors agree that it was a complicated case. How could it have been coded to the DRG without a CC? While the problem may truly complicate that patient’s encounter, it may still not meet the definition of a secondary condition that affects the DRG. Perhaps it only needed a documented cause of the symptoms complicating the case. Here again, education plays a critical part in the success of a clinical review/DRG payment team. The facility’s coding staff and utilization reviewers who communicate with and teach each other—and teach the payor’s staff as well—will see smoother and cleaner revenue cycles than will those who skip this critical step. Last, but certainly not least, is just plain crossing the line. Even the best coders may not find, much less be able to read, every note in every chart. Consequently, the quality assurance staff or an auditor may identify a valid DRG change that needs to be rebilled for corrected payment. Beware the supervisor or consulting agency that only submits DRG increases for rebilling and never mentions the flip side of the coin. Is it really likely that your coding staff only makes errors in one direction? Might someone request a claim to be coded as “acquired deformity” instead of “tattoo” to have expensive excision and skin grafting reimbursed by insurance? If a physician query returns a lower DRG instead of a higher one, would anyone expect the coder to misplace it instead of processing and coding correctly? Coding guidelines must be followed, and any incorrect claim that is discovered must be rebilled for corrected payment, whether the difference is higher or lower. To do anything less puts the facility at risk for—well, you know, that “F” thing again. Educating billing staff, administrators, and even medical staff is probably the best approach to make sure your coders are insulated from undue financial pressures at your facility. The added benefit is that the facility is better protected in case of later audit. A competent, educated coding staff can make the difference between financial and federal success or liability. Be certain that compliance is the first tool they find at hand when they begin their work each day. —Judy Sturgeon, CCS, is the hospital coding senior manager at the University of Texas Medical Branch in Galveston. While her initial education was in medical technology, she has been in hospital coding and appeal management for the past 17 years. |
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