Making Good Decisions in Medical Coding and DRG Assignment Joel - - PowerPoint PPT Presentation
Making Good Decisions in Medical Coding and DRG Assignment Joel Moorhead MD, PhD, CPC Goals Review principles of good decisionmaking Identify and eliminate sources of bias Explore differences of opinion Hospitals Insurance
– Hospitals – Insurance companies / audit contractors
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eaten by a shark or killed by falling airplane parts?
– 30 times more likely to be killed by falling airplane parts
– Plous, Scott. The Psychology of Judgment and Decision. McGraw‐ Hill Higher Education, 1993.
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– Is Easier to Imagine – Is Familiar – Took place recently – Is Highly Emotional
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– Initial impression often too extreme – Insufficient adjustment to new information
– Overconfidence in intuitive decisions
Scrub them off once in a while, or the light won’t come in.” Isaac Asimov
(http://www.goodreads.com/quotes/tag/opinions)
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– We may be more likely to use a code if we:
– But we may overlook important differences in current situation
– But further analysis might support different coding approach
– Mental shortcuts appeal to our “gut” instincts
– Factors important to good decision‐making
» Kahneman, Slovic, and Tversky, 1982
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– Speed of decision‐making – Make information manageable – Often reliable and useful
– Unconscious – Oversimplify complex situations – Accuracy of decision depends on accuracy of cues – Often biased – Intuitive appeal leads to
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– Systematic error
– Often unconscious – Often consistently in one direction
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– Unconscious – May not be based on logic – Often not systematic – Subjective – Not easily measured – Uses shortcuts uncritically – Not based on probabilities – Very important to making good decisions
– Conscious – Based on logic – Systematic – Objective – Measurable – Reduces bias – Based on probabilities – Very important to making good decisions
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– Sensitivity
disease
– The probability of a positive test given that the person has the disease
– Use data that apply to groups
– Not intended to establish final diagnoses for individual patients
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– The ability of a test to identify persons who do not have the disease
disease‐free
– Adds information specific to individual patients
– Sherlock Holmes
– Designed to make final decisions affecting individuals
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– Accurate measure of usefulness of a test in diagnosing disease in an individual patient.
– Percentage of patients with a positive test who actually have the disease
– Percentage of patients with a negative test who are disease‐free
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– Pre‐test probability of disease
– If pre‐test suspicion high for C diff, consider empiric therapy regardless of test results
are not sufficiently high to exclude disease in patients with high pre‐test suspicion of disease
C diff Infections. Am J Gastroenterol 2013 (108):478‐ 498http://gi.org/guideline/diagnosis‐and‐management‐of‐c‐difficile‐ associated‐diarrhea‐and‐colitis 15
– Mitigating factors – Ways that clinical indicators specific to the individual affect interpretation of criteria
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– Meta‐analysis – “More likely than not” legal determinations
– ... that none of the individual pieces of evidence alone can justify.
than not. Journal of Craniofacial Genetics, 1986. 6: p. 203‐206.
systematic reviews: Introducing rigour into the qualitative overview stage by assessing signal and noise. Journal of Evaluation in Clinical Practice, 2000. 6(2): p. 177‐184
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– “Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder.”
clinician or maybe performed by a clinician with approved coding credentials.”
– 2013 CMS Statement of Work for the RAC ‐ DRG Validation vs. Clinical Validation
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– Correlation between one measure and another that is assumed to be superior.
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Hospital
diagnosis
– History, physical exam, diagnostic testing
diagnosis
– supported by clinical indicators in the EMR – consistent with published medical literature
Auditor
physician’s diagnosis
– Non‐physician who never examined or treated the patient
– based on criteria chosen by the insurance company – Without confirming methodology
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true status
test discrimination can be traced to problem of learning the true state of the patient
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– ALJ Hearing is credibly impartial and valid – Vendor under contract to insurance company is not credibly impartial
– Resolution of conflict by mutual agreement
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– Medical record documentation and – Coding guidelines
– Accurate numerical representation of …
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– Physicians – Hospitals – Coders and coding consultants – Auditors
– The Feds
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– Arbitrary
– Capricious
– Bias
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– Making final decisions based on screening criteria ...
– specific to the individual and ... –
» affecting probability of disease in the individual patient
– Final decisions based on internal “criteria” or published criteria different from hospital‐cited criteria but not more “authoritative”
– Criteria inconsistent between auditors and review organizations – Subject to change without explanation or discussion
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– Conventions
– Instructions in the Tabular List
Guidelines.
(Chapter‐specific and General Coding Guidelines) (Coding Clinic 2Q
2007)
– Chapter‐specific guidelines
Guidelines
(Coding Clinic 1Q 2003 ("Respiratory failure due to Pneumocystis carinii d/t AIDS”)
– General coding guidelines
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» Coding Clinic 1Q 2008, page 17
– ICD‐10‐CM Official Guidelines – Clinical findings specific to the patient
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– "The establishment of clinical parameters for code assignment is beyond the scope of authority of the Editorial Advisory Board for Coding Clinic for ICD‐9‐ CM.” (Coding Clinic 1Q 2008 page 3 ("Excisional Debridement")) – The information published in Coding Clinic should not be used as clinical criteria for code assignment. Any clinical information is published in Coding Clinic as background material to aid the coder.
Coding Clinic 3Q 2009 pages 20‐21 (”Respiratory Distress Syndrome of Newborn”)
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(http://www.goodreads.com/quotes/tag/opinions)
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– Speed code assignment and DRG calculation
– Primary source for confirmation of code assignment
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– Review ICD‐10 Conventions and General Coding Guidelines
– Look up the main term(s) in the Alphabetic Index and scan subterms
– Note parenthetical terms (nonessential modifiers)
– Pay close attention to instructions in the Index
Coding 34
– Do not code from the Alphabetic Index without verifying the accuracy of the code in the Tabular List
– Read all the instructional material
disease, instructions, code also, 4th/5th/6th/7th character requirements”
– Consult the ICD‐10‐CM Guidelines
– Confirm and assign the correct code
Coding 35
– Subject is
– Abstract form expresses the underlying reality of the subject
– Expresses underlying reality of the admission
specificity
clinical classification
dense work
Information Management Journal 2011;40(1):14‐20
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the medical records
way to code this!
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– PDx: G54.0 Brachial plexus disorders
– Procedure: 0PT10ZZ Resection right rib – DRG: 29 Spinal Procedures w/ CC
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– No brachial plexus lesion. Only vascular.
– Objective directs ICD‐10‐PCS code assignment.
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– PDx: I87.1 Compression of vein – Procedure: 05N70ZZ Release R axillary vein – DRG: 253 Vascular Procedures w/ CC
– New PDx more accurate – New PPx captured objective of procedure – New DRG identified procedure accurately
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– Procedures: 0LQQ0ZZ Repair R knee tendon 0QSDXZZ Reposition R patella – DRG: 501 Soft tissue procedures w/ CC
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– Musculoskeletal procedure, not soft tissue
– Retinacula are part of quadriceps tendon – Patella is encased within quadriceps tendon
– Expected Inherent/Integral to procedure – Reasonable to remove 0LQQ0ZZ Repair R knee tendon
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– 0LQQ0ZZ Repair R knee tendon – 0QSDXZZ Reposition R patella
– 516 Musculoskeletal OR procedure w/ CC
– New DRG identified procedure accurately
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– Assumption that auditor’s coding would be “superior” to the hospital’s original coding is unjust!
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– Low administrative burden for hospital
– Respectful tone, generally reasonable
– High administrative burden for hospital
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– Request for explanation of coding and sequencing
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– Cardiomegaly increased – Ejection fraction <25% – Malignant hypertension – CXR: pleural effusions, pulmonary edema – Pro‐BNP 3,420 (↓ to 653 two days later)
– Acute on chronic systolic heart failure
– “Our review fails to support picture of acute CHF”
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– BMI <16 – Weight loss >25% – Characteristic signs and symptoms”
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– ≥5 days
– ≥2% over one week – ≥5% over one month – ≥7.5% over three months
– White JV et. Al. Consensus Statement AND/ASPEN: Identification and Documentation of Adult Malnutrition. Journal of Parenteral and Enteral Nutrition May 2012;36(3):275‐283.
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few days
– Criteria for malnutrition may be difficult to document in adult who is acutely, critically ill. – Characteristics for diagnosis of malnutrition may be difficult to discern early in the hospital course due to
NPO)
health status changes over time.
2012;36(3):275‐283.
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– Administrative law judge (ALJ) is level three
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– Acute ‐ chronic ‐ acute on chronic – Mild ‐ moderate – severe
treated or monitored, or affect care
– Document whether present on admission
– "History of" only for past conditions completely resolved
– “AKI could mean ‘Acute Kidney Insufficiency’”
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– Diabetes / HTN / other multi‐system illness
– Congenital anomalies
– Organism(s) responsible for infections – Specific cause(s) of post‐op conditions
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– Pathology reports
– Echocardiogram findings – Lab values – Other diagnostic studies
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– Include instruments used in performance of procedure
– Expected consequence of procedure? – Unavoidable event due to complexity of patient and procedure? – Complication?
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– Patient circumstances and characteristics that support the clinical diagnosis – Strengths and weaknesses of diagnostic tests that make the test itself a guide to diagnosis
– Examples:
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– 24 criteria grouped in five organ systems
definitions conference. (Intensive Care Med 2003;29:530‐538)
– Six parameters Resp, Coag (platelets), Liver (bilirubin), CV (MAP), CNS (GCS), Renal (Cr, urine o/p)
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sepsis in patient who did not meet criteria ...
– WBC count WNL ‐ may have underlying immunodeficiency
– Leukopenia and thrombocytopenia last month
syndrome, bone marrow insufficiency/failure, or hematologic malignancy.
– Rx carvedilol which may be blunting the tachycardic response that we typically see in the setting of sepsis.
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established by two of three criteria ...
– Abdominal pain consistent with the disease – Amylase and/or lipase > 3x upper limit of normal – Characteristic findings on abdominal imaging
– American College of Gastroenterology Guideline, 20 July 2013
– Diabetes, anatomical factors, previous surgery?
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– One payment for physician + facility – Hospitals contract with physicians to share risk
– Payment of Physician claim may depend on payment of Facility claim
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Integrity, Transmittal 505, 2/5/2014
– If documentation associated with one claim is used to validate another claim, those claims may be considered “related.”
and necessary, and therefore the physician claim can be determined to be not reasonable and necessary.”
reasonable and necessary, and therefore the professional component can be determined to be not reasonable and necessary.”
to depend on accurate documentation
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– Acute pancreatitis
– “Not a valid diagnosis” – Insurance Contractor
– Unspecified Abdominal Pain
– “Not medically necessary” – RAC auditor
– Admission not MN, ∴ Physician services not MN
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“Pneumonia is a clinical diagnosis.
– May be supported by one or more of the following clinical indicators
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– Physicians will be asked to order medically‐ unnecessary tests
– Not appropriate to order medically‐ unnecessary diagnostic test to assign a code when a clinical diagnosis has been established
– http://www.cms.gov/Medicare/Coding/ICD10/downl
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Coders work together with medical staff – Guidelines that promote complete documentation for coding – Must be applied consistently to all records coded. – Guidelines do not replace physician documentation to support code assignment.
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QIO
records
discussion with physician
physician available for discussion
Audit contractor
pneumonia.”
be removed.”
name or credentials
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Anais Nin
– Training and Experience – Natural preferences – Incentives and Goals
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– Discuss of patient’s explanatory model – Discuss of physician’s explanatory model
– Compare patient and physician models – Mutually accepted explanation of illness
– Mutually‐accepted treatment plan
» Based on Kleinman, A. (1978). "Clinical relevance of anthropological and cross‐cultural research: Concepts and strategies." Am J Psychiatry 135: 427‐ 431.
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– Meeting #1
– If no agreement » Agree to meet again » Research
– Meeting #2
– Assess strength of support for each coding approach – If no agreement, consider for a day or two
– Meeting #3
– Avoid arguing over information presented previously
– One coding approach significantly better supported
– Both coding approaches reasonable
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– “... Bohr is one of the amiable colleagues I have
groping and never like one who believes himself to be in possession of the truth.”
http://www.goodreads.com/quotes/tag/opinions?page=8
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– Coding question? – Medical question? – Both?
medical questions
– Consider both together only in final analysis
– We look harder for flaws in reasoning when we disagree with the conclusion.
8/16/2010
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– All points of view – Cultural norms – Power relationships – Organizational realities
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– Restate – don’t repeat – Adjourn if progress stops
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rapid or irregular heart rhythm
the brake and the car not slowing down.
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Data Model
– Current practices efficient
– Resolution ‐‐ Telephone discussion of proposed coding change as offered by QIO
for accuracy
“Financial” model
– Current practices inefficient
– Resolution ‐‐ Telephone discussion before denial letter ever written
TC cannot be doubted
proxy for accuracy
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– ... to the greatest extent possible.
– Open discussion resolves differences.
– Agreement between hospital and payor – Impartial third party review
– Message in listener’s frame of reference
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