Most Common DRG’s with Recommendations 2019: #3
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
We’re half way through the countdown with today’s coding tidbit. Just to recap, HIA reviewed over 50,000 inpatient records in 2019. We are counting down to # 1.
#3 DRG with the most recommendations during HIA reviews
DRG 190—Chronic obstructive pulmonary disease with MCC
The majority of the recommendations from DRG 190 (Chronic obstructive pulmonary disease with MCC) were due to changes in the PDX (only 9% required a query). The most common PDX change was to re-sequence acute respiratory failure as the PDX or add the diagnosis of acute respiratory failure and sequence as the PDX (nearly 100% of these did NOT require physician query for clarification). The next most common PDX change was re-sequencing or adding pneumonia (either unspecified or specified type) and sequencing as the PDX (only 17% of these required a physician query for clarification). The third most common reason for DRG changes was deletion of the MCC (the majority of these did require a physician query for clarification). Most of these queries were sent to clarify if the MCC was ruled in or out, or if it was clinically significant to report. Coders cannot ignore physician documentation, but also need to query to clarify when it is not clear in the record that a condition truly exists or was ruled out. DRG 190 was reported accurately only 80.59% of the time based on records reviewed by HIA in 2019 (474 records reviewed).
What can coders do to improve accuracy of DRG 190?
- Coders should look for the diagnoses of pneumonia and acute respiratory failure when patients are admitted with COPD exacerbation. Oftentimes, it is one of those two conditions that inpatient treatment is needed for.
- If patient does have several respiratory issues on admission, it may be that one is the focus of admission over the others. There is no way to make a statement that would fit all coding scenarios and that is why each record must be reviewed in detail to determine which condition should be reported as the PDX.
- If acute respiratory failure is present on admission and documented as the focus and reason of the admission, it is very likely that this will be the PDX as this is the urgent/life threatening condition requiring admission. Again, all records must be reviewed in full to determine the appropriate PDX.
- Validate all MCC’s to ensure that documentation is in the medical record to support that these conditions should be reported. If there’s a chance that the condition may be ruled out, a query should be sent for clarification. When only 1 MCC is present on a record it is always best practice to double check to ensure that the condition meets reporting requirements as well as clinical validity so that it is protected in any audits.
- If there is a question about a diagnosis in the record that does impact the DRG, a query should be sent or coders should follow the procedure for their facility to escalate the record to a senior reviewer or physician liaison.
- Use the latest coding reference for sequencing COPD and pneumonia as this did change effective October 1, 2017 (instructional note changed from “use additional code to identify the infection” to “Code also to identify infection”). Even though this change was a couple of years ago, we still see coders following the older guidance.
- Query anytime there is ambiguous of conflicted documentation prior to coding finalization
- Bottom line is to protect the DRG at final coding by making sure that it is correct, and that there will be no question after final billing about the ICD-10-CM and/or ICD-10-PCS codes that were reported. Be sure and check for mechanical ventilation on these patients.
Coders should review the entire medical record to look for any conflicting documentation and clarify this prior to final coding. Clarification prior to final coding will decrease audit recommendations and denials. Remember, denials are costly to the facility with all the time that is spent trying to appeal.
Be on the lookout for the #2 most common DRG recommendation for 2019.
ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting FY 2020
ICD-10-CM/PCS Coding Clinic, Fourth Quarter 2017 Pages: 96 and 110
ICD-10-CM/PCS Coding Clinic, Fourth Quarter 2016 Pages: 147-149
ICD-10-CM/PCS Coding Clinic, Third Quarter 2016 Pages: 15-16
ICD-10-CM/PCS Coding Clinic, First Quarter 2017 Page: 24
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
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