Falling Case Mix Have You Confused?
The ICD-10-CM/PCS code changes – effective October 1, 2018 to September 31, 2019 – could be the culprit.
Comparatively speaking, there are far less changes this year than in years past. The release includes:
- 279 new codes
- 51 deleted codes
- 143 revised codes
But don’t let the smaller amount of changes fool you. During many of our recent reviews, our findings show a big impact when it comes to case mix.
For example, Encephalopathy. Here’s how:
Case 1: Patient admitted for subtrochanteric femur fracture. The patient had operative repair of the fracture with an ORIF. Postop the patient had some confusion the provider documented “acute encephalopathy post op. Likely due to post-anesthesia.”
The coder reported the appropriate principal diagnosis and procedure code but assigned G9340, Encephalopathy unspecified, as a secondary diagnosis. Prior to October 1, 2018 unspecified encephalopathy would have been considered an MCC. The DRG would have been 480, Hip & Femur Procedures Except Major Joint W MCC, CMS weight 3.0304. Post 10/1/2018 unspecified encephalopathy is no longer considered an MCC, but toxic encephalopathy is. Documentation in the record suggests that the encephalopathy may have been caused by the anesthesia. A query to the provider to document the cause/type of the encephalopathy could impact the DRG.
- Pre 10/1/2018 – DRG 480, Hip & Femur Procedures Except Major Joint with MCC, Wt. 3.0304
- Using $5500 as the base rate $16,667.20
- Post 10/1/2018 – DRG 481, Hip & Femur Procedures Except Major Joint with CC, Wt. 2.0623
- Using $5500 as the base rate $11,342.65
- Resulting in a decrease of 0.9681 to the case weight and a reduction of $5,324.55 to reimbursement
Better documentation for the cause/type of encephalopathy could potentially support DRG 480 post 10/1/2018.
Case 2: Patient admitted for hyponatremia and encephalopathy. Documentation on the H&P stated the encephalopathy was metabolic. The coder assigned the appropriate code for hyponatremia as the principal diagnosis. The coder assigned G9340, Encephalopathy unspecified, as a secondary diagnosis.
Documentation in the H&P did support a more specific code for Encephalopathy and code G9341, Metabolic Encephalopathy, could have been reported. The more specific code for Metabolic Encephalopathy is still considered an MCC post 10/01/2018. Unspecified encephalopathy is not.
- Pre 10/1/2018 – DRG 640, Misc Disorders of Nutrition, Metabolism with MCCC, Wt. 1.1902
- Using $5500 as the base rate $6,546.10
- Post 10/1/2018 – DRG 641, Misc Disorders of Nutrition, Metabolism Without MCC, Wt. 0.7519
- Using $5500 as the base rate $4,135.45
- Resulting in a decrease of 0.4383 to the case weight and a reduction of $2,410.65 to reimbursement
Documentation in the record supported a more specific encephalopathy code. The documentation could have been better or documented more during the encounter. However, reporting the more specific code would support DRG 640 post 10/1/2018.
Educate Your Staff with HIAlearn
HIA can provide your coding staff with a comprehensive understanding of these changes via HIAlearn.
Our learning management system provides your staff with on demand access and the flexibility you need to set a training schedule that meets individual needs.
- ICD-10-PCS New Codes FY2019: This two and one half (2.5) hour session, with accompanying aptitude quiz, focuses on the additions/deletions/revisions to ICD-10-PCS, including guideline changes. This session is approved for 2 AHIMA CEUs.
- ICD-10-CM New Codes FY2019: This two and one half (2.5) hour session, with accompanying aptitude quiz, focuses on additions/deletions/revisions for ICD-10-CM for FY2018, including guideline changes. This session is approved for 3 AHIMA CEUs and/or 2.5 AAPC CEUs.
- FY2019 IPPS Changes: This approximately one and one half (1.5) hour session focuses on changes in MS-DRG assignment, reimbursement updates and MCE edits to the IPPS for FY2018. This session is approved for 1.5 AHIMA CEUs.
Our extensive Action Plan Library provides targeted and interactive sessions in an easily digestible format, including one on “Encephalopathy, Altered Mental Status, Dementia and Delirium Coding.”
The Code Hard Truth: Every Code Counts
Complete and accurate documentation + Complete and accurate coding = Complete and accurate reimbursement.
Many of our client partners have reached out to validate that their coding staff has a good understanding of the ICD-10-CM/PCS and IPPS changes with a comprehensive review.
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Answer: I would code 0HPT0NZ for removal of tissue expander from right breast, open and change 0HPT0JZ, removal of synthetic substitute from right breast, open, for removal of the acellular dermal matrix to 0HPT0KZ, Removal of nonautologous tissue substitute from right breast, open approach.
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A California-based healthcare services provider and several of its affiliates have agreed to pay $30 million to resolve allegations they submitted inaccurate information about the health status of beneficiaries enrolled in Medicare Advantage Plans, according to the Department of Justice.
Happy National Volunteer Week! This week we celebrate the impact volunteer work has on building stronger communities. We know that our staff have a positive impact while they’re on the job, and we are proud to share a few ways our #PeopleBehindTheNumbers are taking time to volunteer in their own local communities.
Scrutiny of coding compliance in the growing ambulatory surgical center (ASC) market has increased in recent years from both Medicare and private payers. This will only increase as the Centers for Medicare and Medicaid Services (CMS) moves towards value-based care.
Patients being admitted for acute renal failure due to dehydration have been happening for many, many years now. Typically what happens is a patient gets dehydrated for one reason or another. Once dehydration sets in, it can quickly start to affect many body organs. This can lead to acute renal/kidney failure/injury.
In December 2018, a Pennsylvania for-profit hospital and health system, and its CEO agreed to pay a total of $12.5 million to settle allegations they submitted false claims to Medicare and other federal health care programs for orthopedic surgeries. The settlement resolves allegations that top executives exploited a loophole – AKA modifier 59 – that allowed them to double bill federal healthcare payers for surgeries and ignored coding consultants who advised them that they were improperly billing.
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