Most Common DRG’s with Recommendations 2019: #4
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
As stated in yesterday’s coding tip, HIA reviewed over 50,000 inpatient records in 2019. We are counting down to the # 1 DRG change for HIA in 2019. Any guesses to what that would be?
#4 DRG with the most recommendations during HIA reviews
DRG 193—Simple pneumonia & pleurisy with MCC
The majority of the recommendations from DRG 193 (Simple pneumonia & pleurisy with MCC) were due to changes in the PDX (75% without query being needed). The most common findings were coding the pneumonia to a more specific bacterial pneumonia or aspiration and sepsis being reported as the PDX. The second most common reason for DRG changes from 193, is taking away the MCC (about 1/3 of these did require a query). The MCC’s were not clearly documented in many of the records that fell into the review and required queries to clarify the validity of the diagnoses (MCC). DRG 193 was reported accurately only 88.82% of the time based on records reviewed by HIA in 2019 (778 records reviewed).
ICD-10-CM code J18.9 -Pneumonia, unspecified organism, was the 6th most reported diagnosis with either additions, deletions and/or revisions during HIA inpatient coding reviews in 2019. This code was reported correctly only 86.28% of the time.
What can coders do to improve accuracy of DRG 193?
- Review the medical record for further specificity of the type of pneumonia documented (specified bacteria or aspiration)
- Clarify if the diagnosis of sepsis is also documented and supported in the record and if so determine if it was present on admission and should be sequenced as the PDX
- Query anytime there is ambiguous or conflicted documentation prior to coding finalization
- Review the operative notes for details of “lung” being biopsied during bronchoscopies. There were a few changes based on the PCS code being changed from bronchus to lung
- Was acute respiratory failure also present? If so, is the focus of the admission?
- Did the patient present with more than one potential PDX? If so, review the medical record to determine if equal treatment was given or if one of the diagnosis was the focus of the admission. There were 9 records where congestive heart failure was sequenced as the PDX during these reviews
- Verify if the patient has a lung transplant and if so, is the pneumonia in the transplanted lung
- 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.
- Bottom line is to protect the DRG at final coding by making sure that it is correct, and there will be no question after final billing about the ICD-10-CM and ICD-10-PCS codes that were reported
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 #3 most common DRG recommendation for 2019.
ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting FY 2020
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.
Why are so many AKI records being denied? It’s hard to give one answer for why so many AKI records are being denied lately, but most appear to be due to the multiple sets of criteria available for use in determining if a patient has AKI, as well as physician documentation. As stated in Part 3 of this series, there are three main criteria/classifications used to diagnose AKI.
In previous parts of this series we looked at the definitions of AKI/ARF, causes, coding and sequencing, and the common clinical indicators that patients present with that are diagnosed with this condition. In Part 4, we will look at the documentation that should be present to report the diagnosis without fear of denial, as well as when a query is needed to clarify the diagnosis.
If the facility does a COVID-19 test, and test is negative, do I need a diagnosis code. The answer is yes, you will report a Z-code. The Z-code depends on the record documentation and circumstances of testing. For any patient receiving a COVID-19 test, if negative, there MUST e a Z-code to describe why the test was taken. (Test negative for COVID-19 and MD does not override negative results).
In the first parts of this series we looked at definitions of AKI/ARF, causes, coding and sequencing. In Part 3, we will look at what clinical indicators would possibly be present to support the diagnosis of AKI/ARF.
The FY2021 IPPS Proposed Rule is out and here are some highlights from it regarding ICD-10 Code proposals. We will know if these changes are permanent after the public comment period is over on July 10, 2020 and CMS prepares the Final Rule, usually out by August 1.
As discussed in Part 1 of this series, AKI/ARF is a common diagnosis that coders see daily. In Part 2, we are going to focus on the different types/specificity of AKI/ARF. We’ll learn what they mean, as well as how to code the diagnosis.
This is part 1 in a series focused on coding of acute kidney injury (AKI) and/or acute renal failure (ARF). AKI/ARF is reported often, but is also one of the most common diagnosis found in denials.
With the proliferation of COVID-19 cases, we thought we would put together a quick reference listing of some of the common scenarios that coders have asked about. As with all coding, coders should follow Official Guidelines for Coding and Reporting and the COVD-19 Frequently Asked Questions document by the AHA.
Effective March 1, Medicare will pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19. This great for providers whose patients are reluctant to visit the office.
The biggest reasons why some hospital systems are moving to single path coding is to eliminate duplicative processes and to optimize productivity. In addition, costs are reduced when only one coder “touches” the record and completes both types of coding.
Effective with 4/1/2020 discharges, ICD-10-CM code U07.0 is used to report vaping -related disorders. ICD-10-CM code U07.0 (vaping related disorder) should be used when documentation supports that the patient has a lung-related disorder from vaping. This code is found in the new ICD-10-CM Chapter 22. U07.0 will be in listed in the ICD-10-CM manual under a new section: Provisional assignment of new disease of uncertain etiology or emergency use.
The US government and public-health officials are urging consumers to utilize telemedicine for remote treatment, fill prescriptions and get medical attention during the new coronavirus pandemic. The goal is to keep people with symptoms at home and to practice social distancing if their condition doesn’t warrant more intensive hospital care.
Coronavirus: Tips for working from home. Companies around the world have told their employees to stay home and work remotely. Whether you’re a new to this concept or a work from home veteran, here’s some tips to staying productive from our #HIAfamily.
This is the final part of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. In this part, we provide an actual example of an effective communication response to CDI.
This is part two of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. In this part, we discuss mismatches and how to best go about resolving them. In part three we will provide a case example of best practice interaction.
This is part one of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. Many times these departments are separate and the remote environment makes it difficult to interact efficiently between the two departments. In part one, we will discuss the history and objectives of CDI so the coder has a better understanding of CDI’s role.
One reason that coders should report chronic conditions (including history and status codes) on outpatient records is the HCC’s—Hierarchical Condition Categories. The quick and easy explanation of what HCC’s are is each HCC is mapped to certain ICD-10-CM codes or code ranges. HCC coding is designed to estimate future health care costs for patients.
For Part 5 of this 5-part series, we will look at Chapter 4 within ICD-10-CM—E00-E89—Endocrine, Nutritional, and Metabolic Diseases. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 4 of this 5-part series, we will look at Chapter 10 within ICD-10-CM—J00-J99—Diseases of the Respiratory System. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 3 of this 5 part series, we will look at Chapter 9 within ICD-10-CM—I00-I99—Diseases of the Circulatory System. This chapter contains so many of the everyday diagnoses that we code such as hypertension, heart disease and stroke.
For Part 2 of this 5-part series, we will look at Chapter 1 within ICD-10-CM—A00-B99—Certain Infectious and Parasitic Diseases. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 1 of this 5-part series, we will look at Chapter 21 within ICD-10-CM—Z00-Z99—Factors influencing health status and contact with health services. There is no possible way to include every guideline or coding reference for this chapter, but I’ll do my best to touch on some off the most common issues.
The HIM world has been buzzing recently with discussion of “Social Determinants of Health” and coded data. What does this mean for coders and the HIM field?
The Centers for Disease Control and Prevention (CDC) is in process of developing a new code for the COVID-19 (coronavirus) that will be released October 1, 2020. In the meantime, the CDC has provided advice on coding the COVID-19 coronavirus.
We’re finally at the #1 most common DRG with recommendations by HIA for 2019. Just to recap, HIA reviewed over 50,000 inpatient records in 2019. Most have probably already guessed what the correct DRG would be with the most recommendations. There are just some diagnoses and DRG’s that will always be a thorn in the side for coders. #1 DRG with the most recommendations during HIA reviews : DRG 871—Septicemia or severe sepsis w/o mechanical ventilation >96 hours with MCC
We’re now at the second most common DRG with recommendations by HIA for 2019. Just to recap, HIA reviewed over 50,000 inpatient records in 2019. We are counting down to # 1. #2 DRG with the most recommendations during HIA reviews: DRG 872—Septicemia or severe sepsis w/o mechanical ventilation >96 hours w/o MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #3 DRG 190—Chronic obstructive pulmonary disease with MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #5 DRG with the most recommendations during HIA reviews : DRG 853—Infectious & Parasitic diseases with O.R. procedure with MCC
Pivotal moments in the Health Information Management field include the implementation of ICD-10, CPT Coding Changes, Acute care changes, profee changes, recovery audit contractor implementation, new ransomware challenges, Meaningful use and much more.