November 12, 2007

Pressure Points 2008
By Judy Sturgeon, CCS
For The Record
Vol. 19 No. 23 P. 6

Coders and billers aren’t the only ones acutely aware of the headaches on the horizon for hospitals in this new fiscal year. Facility compliance officers are also finding plenty of job security thanks to the significant changes made by the Centers for Medicare & Medicaid Services (CMS) this October. At first glance, the new Medicare severity diagnosis-related groups (MS-DRGs) and their requirement to add a present on admission (POA) indicator may seem to be strictly coding and billing issues. However, it is critical to remember their connection to compliance: Anything that can change your payment from the CMS leaves open the chance—and even the opportunity—to do it wrong, thereby submitting a false claim.

The first pressure point is in trying to assign a DRG in a system that has expanded from 579 CMS DRGs to 745 new severity-adjusted MS-DRGs. The old system was based on submitted charges; the new one will transition to a cost-based payment determination. This adds compliance concerns for making sure that the facility cost report is correct. In addition, a stunning 273 of them will be affected by the patient’s discharge status. Is your facility getting the documentation it needs to ensure correct discharge disposition codes on the claim so that correct payment is received on the new transfer DRGs?

In the old system, if a DRG was affected financially by significant complications and comorbidities (CCs), only one was needed and subsequently counted. Under the new system, there are DRGs with major CCs, minor CCs, and no CCs. The industry had hopes that treatment of multiple significant medical problems would result in multiple levels of increasing reimbursement, but as it stands now, that does not seem to be the case. A patient with six minor CCs will still be in the same DRG as a similar patient who has only one minor concurrent issue. While this is disheartening to large acute care facilities that expected better reimbursement for their sicker patients, it at least reduces the related risk of inappropriate overcoding to capture potential multiple levels of reimbursement. While this single issue reduces the risk, most changes will result in more problems, not less.

Many of the old standard diagnoses, such as congestive heart failure (CHF), simple dehydration, and chronic blood loss anemia, no longer make the grade for payment increase. To achieve CC status for CHF, the physician must now document acute systolic or diastolic heart failure, not just CHF. Unspecified and chronic conditions galore have been dropped from all CC lists. Will there be temptation for the coder to presume that a diagnosis must be acute? Could it be financially rewarding to lead the physician in querying for more specific diagnoses? You can be assured that the pressure will be strong in both instances.

As if the above situations aren’t sufficient to send your compliance officers running for the office Tylenol supply, consider the CMS’ intent to presume that everyone will now code more completely, thereby artificially increasing hospital payments. Based on this assumption, the CMS has built in a reduced payment intended to keep the new system budget neutral. While the official term for this is a behavior offset, those in the trenches refer to it as DRG creep.

What does this have to do with compliance? If the coding staff doesn’t code more significant diagnoses than it did previously, the facility is at risk to miss reimbursement. But if they’ve been doing a great job all along, this negative payment adjustment is unfairly penalizing coding-compliant departments by reducing their overall payment by the same percentage as everyone else’s. Should your state associations take a stand and petition the CMS and the federal government to change this process? It’s certainly an option to consider if Congress doesn’t step in and take control of this unfair penalty.

A second major pressure point will start cerebral arteries throbbing as coders attempt to determine which of the diagnoses were POA and which were not. If the documentation isn’t clear, the next decision that needs to be made is when the physician is clinically unable to determine whether the diagnosis was POA or the information in the chart is too vague to confirm. Should the latter be the case, the coder will need to—you guessed it—query the physician for further clarification.

Again, this seems like a coding and documentation problem, not a cause for concern for the compliance department. The CMS, however, had intentions besides data reporting in mind when it mandated this new procedure. Despite its history of using data to improve processes rather than punish the reporter, in this circumstance, the inverse is true. For eight specific diagnoses acquired after admission, that diagnosis will be exempted from CC status in assignment of MS-DRGs to the patient. While some of the eight are rare problems, such as leaving foreign bodies in the patient during surgery, air embolisms, and giving ABO-incompatible blood products, some of them are all too common.

Infections associated with urinary and vascular catheters can be ambiguous in their source and documentation, especially if the patient was treated somewhere prior to admission. In-house injuries, pressure ulcers, and mediastinitis after coronary bypass surgery are more diagnoses on the CMS’ no-payment hit list. Will the fiscal risk keep staff from documenting honestly when an infection is due to the catheter or an injury occurred after admission?

Conversely, does your staff have a process to query for details regarding the likely date of onset for these diagnoses in at-risk cases treated at your hospital? Consider the nursing home patient who already has an in-dwelling catheter or the febrile patient admitted to work up the cause and whose specific symptoms initially appear at a site of physical insult such as an intravenous catheter. This type of ambiguity must be documented in detail to validate whether the onset was truly prior to admission, after admission, or clinically unable to be determined. Here again, we find reason for unease: Any time there is temptation to alter or delete documentation based on payment, compliance risk exists.

The new coding year appears to present hospital compliance departments with numerous potential headaches. What can be done besides hand-wringing and worrying? Consider the two major issues previously outlined and set up an action plan that covers the following needs:

• Be informed.

• Provide education—in fact, require education.

• Audit processes.

• Monitor results.

• Take corrective action as needed.

But remember, if the compliance headaches are severe enough to get you admitted to a hospital, make certain that your physician documents that it was POA and whether it qualifies as acute or chronic.

— Judy Sturgeon, CCS, is the hospital coding senior manager at The University of Texas Medical Branch in Galveston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and appeal management for the past 18 years.