Dan Kaelin, M.D. Vascular Surgery Associates Tallahassee, Fl

Dan Kaelin, M.D.
Vascular Surgery Associates
Tallahassee, Fl
— Chad Linville, ARNP, DNP
— W.L. Gore
I am not a coder nor do I understand fully the DRG coding
system
— In 1982, Congress mandated the creation of a prospective
payment system (PPS) to control costs. Congress looked at
the success of State rate regulation systems in controlling
costs and mandated the implementation of a prospective
payment system model that had been successful in several
States. This system is a per-case reimbursement
mechanism under which inpatient admission cases are
divided into relatively homogeneous categories called
diagnosis-related groups (DRGs). In this DRG prospective
payment system, Medicare pays hospitals a flat rate per
case for inpatient hospital care so that efficient hospitals
are rewarded for their efficiency and inefficient hospitals
have an incentive to become more efficient.
— DRGs classify all human diseases according to the
affected organ system, surgical procedures performed
on patients, morbidity, and sex of the patient.
— The classification also accounts for up to eight
diagnoses in addition to the primary diagnosis, and up
to six procedures performed during the stay.
Too Difficult to describe
— Evaluate hospital coding for aortic endografts
— Compare coding to a retrospective review of records
— Third party evaluation of results
— Suggest plan for improvement with assumption we
were not doing it right
— Continued technology advances must be funded
(fenestrated time/cost)
— Hospitals facing decrease reimbursement
— Non-clinical personnel making device purchasing
decisions
— Physicians and hospitals frequently detached from
each other relative to billing
— Two Diagnosis Related Groups (DRG) used by
hospitals to bill for surgical repair of AAA using
endografts.
— DRG 237 is used when the patient has a documented
medical history that includes one of the 1,623 ICD-9
codes considered a major complicating condition
(MCC).
— DRG 238 is used when they do not.
— Average charge per case
— DRG 238 - $81,178
— DRG 237 - $157,569
— Percentage of cases coded
— DRG 238 – 89.7%
— DRG 237 – 10.3%
Hospital
DRG 238
DRG 237
TMH
89.7
10.3
1
83.3
16.6
2
92.9
7.1
3
95
5
4
91.3
8.7
5
89.5
10.5
6
87.3
12.7
7
100
0
8
84.6
15.4
Hospital
DRG 238
237
DRG 238
237
TMH
$81,000
10.3
$158,000
89.7
1
$80,000
16.6
$109,000
83.3
2
$123,000
7.1
$219,000
92.9
3
$73,000
5
$126,000
95
4
$95,000
8.7
$134,000
91.3
5
$118,000
10.5
$201,000
89.5
6
$107,000
12.7
$153,000
87.3
7
$141,000
0
100
$0
8
$77,000
15.4
$137,000
84.6
— EMR review of medical records
— 114 patients (10/1/2008 to 9/30/2011)
— Only surgeries completed by a surgeon from VSA at
TMH
— Clinical notes, operative notes, problem lists and
documentation from other providers and healthcare
facilities were reviewed from VSA’s EMR, TMH EMR and
community HIE.
— Two review passes Performed
— First conservative
— Second aggressive
— Exhaustive review of the images for dissection not
completed in this review
— 15 of 114 patients (13.2%) appeared to have a MCC
adequate to bill DRG 237
— This compares to 8.8% billed by TMH for the same
patient population.
— Most common diagnoses were AAA rupture or
dissection and respiratory failure following surgery.
Co-morbidity
AAA Rupture or Dissection (441.3, 443.22)
Respiratory Failure Following Surgery (518.51)
Cardiac Arrest (427.5)
Acute on Chronic Heart Failure (428.23, 428.43)
Acute MI (410.91)
End Stage Renal Disease (585.6)
Postoperative Shock (998.01)
Vascular Myelopathies (336.1)
Total
Frequency
3
3
2
2
2
1
1
1
15
Rate
20.0%
20.0%
13.3%
13.3%
13.3%
6.7%
6.7%
6.7%
— Five cases did not match the review
— Two patients identified as DRG 238 were billed by the
hospital without using a DRG code.
— One billed for DRG 226 (cardiac defibrillator implant
without catheterization and with MCC)
— One billed for DRG 254 (other vascular procedures w/o
MCC)
— One was identified by the vascular surgeon as having
an iliac dissection, which is considered a MCC, but was
billed by the hospital using DRG 238
— 34 of 114 patients (29.8%) appeared to have a MCC
adequate to bill DRG 237
— This compares to 8.8% billed by TMH for the same
patient population.
— Myocardial infarction and stroke became the leading
MCC qualifying diagnosis codes.
Co-morbidity
Myocardial Infarction (410.11, 410.41, 410.51, 410.91)
Stroke (433.11, 434.91)
Other (336.1, 415.19, 482.9, 530.21, 585.6, 998.01)
Acute on Chronic Heart Failure (428.23, 428.43)
AAA Rupture or Dissection (441.02, 441.3, 443.22)
Respiratory Failure Following Surgery (518.51)
Cardiac Arrest (427.5)
Total
Frequency
9
6
6
4
4
3
2
34
Rate
26.5%
17.6%
17.6%
11.8%
11.8%
8.8%
5.9%
— More than the 8 week rule used if felt a risk factor for
the procedure
— Example
— MI in last 90 days preop (outside 8 week window)
— Stroke felt to effect recovery from procedure
— Bleeding ulcer within 30 days of procedure
— Price Waterhouse
— Reviewed all our findings both passes
— 24 additional patients we felt should have been coded
with MCC they agreed with 7
— Details sent to hospital for review
— Combination of lack of hospital documentation and
coding error
— Dissection of Aorta/Iliac
— Pulmonary Insufficiency
— Injury to inferior mesenteric artery
— Injury to just about any vessel
— C-diff
— Diarrhea of presumed infectious origin
— Lung Cancer
— Clotting disorder
— ETOH withdrawal
— Hypertensive chronic kidney disease, malignant, with
chronic kidney disease stage I through stage IV, or
unspecified
— Hypertensive heart and chronic kidney disease,
malignant, without heart failure and with chronic
kidney disease stage I through stage IV, or unspecified
— A-flutter
— SVT
— Chronic systolic heart failure
— Arterial embolism
— Phlebitis and thrombophlebitis of other sites
— Lower extremity ulcer
— Injury to saphenous vein
— BMI > 40
— 5 ft 9 in and 270 lbs
— Coding is complicated
— Significant disconnect between hospital coding and
physician documentation
— Important outside documentation not available to
coders
— Lack of physician understanding of the rules
— Exposes hospital to reduction in reimbursement and
potential audit failure
— Working with hospital to have more documentation
available to coders
— Educate physicians on important documentation
points to include
— Continue to educate CMS on diagnoses that effect care
and outcomes