Pneumonia Coding - HCPro

1 A supplement to Opus Communications publicationsPneumoniaCodingPneumoniaCodi ngPneumonia coding2 Table of contentsCoding Pneumonia what coders must know ..3 Gloryanne Bryant, RHIT, CCS, discusses why Pneumonia Coding is still a risk area, determining specificity, how to query the physician, and query form ..5NJ hospital self-discloses Pneumonia Coding errors ..6 Hackensack University Medical Center recently settled with the government due to Pneumonia upcoding. Here s what the hospital has done to make sure it stays in look at the government s upcoding project.

2 7 Hackensack University Medical Center isn t the only facility to settle with the government in 2002. Let these other hospitals serve as a overpayments: Be the first to tell the government ..8 Making Coding errors is not the problem, it s how you respond to will happen with ICD-10? ..19 Benchmarking your Pneumonia caseload ..10 Benchmarking should be an important part of your compliance efforts. Here s how to compare your data to that of other hospitals to determine risk shows lots of effort, few worries.

3 12 Hospitals share their level of concern over Pneumonia miscoding and what they re doing to combat it. PROs turn DRG data into Coding tools ..13 Three state quality improvement organizations share their Pneumonia miscoding review worksheet ..14 Dear reader:BCCSis pleased to present this 16-page special report on Pneumonia upcoding. The government s investigationinto this Coding problem has yielded more than $40 million so far with no sign of stopping. This report is designed to serve as a reference guide and resource as you work to make sure your pneumoniacoding and billing is as accurate as possible.

4 With that in mind, we have included information about physicianquerying, benchmarking, how to self-disclose overpayments, self-auditing, and look forward to continuing to provide you with timely, pertinent information and tools to help you in yourcoding compliance ,Beth Easley, MAManaging EditorPneumonia coding3by Gloryanne Bryant, RHIT, CCSHave you noticed we are still seeing settlement agree-ments associated with diagnosis-related group (DRG) Pneumonia Coding ? Yes, it s still a risk area. Using DRGs, you can classify Pneumonia as either simple or complex, and in general terms as either viral/unspecified or bacterial (including aspiration).

5 The two medical DRGs classified to Pneumonia are DRG 089 (simple Pneumonia & pleurisy, agegreater than 17 with CC) DRG 079 (respiratory infections and inflammations,age greater than 17 with CC) National MedPAR (Medicare Provider Analysis Review)statistics from 1999 indicate that DRG 79 representedapproximately 25% of all DRG 89/79 cases. Bench-marking data show that bacterial Pneumonia accountsfor about 3% of the total cases of Pneumonia . When afacility exceeds this percent benchmark by more than5%, it can send out a red flag.

6 Keep in mind that theOffice of Inspector General does not just review lastyear s charts; it may go back five to nine years. Havingclinical documentation in the medical record that de-scribes what type of Pneumonia or the causal organ-ism/agent is specificityCoders should assign the ICD-9-CM code for pneumoniathat reflects the greatest specificity documented in thebody of the medical record by the physician, such asStaphylococcal Pneumonia , aspiration Pneumonia , gram-negative Pneumonia , or Pseudomonas Pneumonia .

7 Notonly does using the most specific code provide accuratestatistics for your facility, it also helps to reflect the sev-erity, acuity, and risk of mortality. It also protects yourfacility from government investigations. We know thatcoding for greatest specificity depends on accurate andthorough physician documentation. This is the center ofthe issue. The American Hospital Association sCodingClinic,2nd Quarter 1998, provides the following guide-lines for Coding Pneumonia : Never assume Do not assign codes based on lab or x-ray values aloneCoding Pneumonia what coders must know For documentation purposes, review linkage ofsputum culture results to the Pneumonia Code as specifically as possible, based on physi-cian documentation Review the entire medical record for clarityQuerying the physicianWhen documentation is unclear, ambiguous, or incon-clusive, the coder should query the physician for clari-fication.

8 When assigning codes for diagnoses addressedin the consultant s report, review all documentation tomake sure there is no contraindication from the attend-ing physician. You should be careful when querying notto lead the physician into documenting a particular di-agnosis that is not supported by the clinical picture. TheCenters for Medicare & Medicaid Services have decidedto allow physician query forms to remain as a perma-nent part of the medical record when the physicianresponds to them. See p. 5 for a physician query form specific to pneu-monia, used at San Francisco s Catholic Healthcare physician query form can be used on a concurrentbasis (by both Coding /health information management(HIM) and case management staff) and also retrospec-tively.

9 Your facility or organization should have a phy-sician query form and usage policy to help guide thecoding and case management staff on proper should use caution when Coding Pneumonia ,unspecified, code 486, (although this is a very commonpneumonia code), when there is clinical evidence of amore specific type of Pneumonia being treated. In thiscase, a query to the physician would be with the case manager or nursing clinicianscan also help in this Clinicreminds us to use code 486 only whenneither the diagnostic statement nor a thorough reviewof the record provides documented information to allowfor a more specific code.

10 When the physician documentsatypical Pneumonia , community-acquired Pneumonia ,assign code 486 ( Pneumonia , organism unspecified). As-sign code ( Pneumonia due to other specifiedbacteria) when there is documentation of a specifictype of bacterial Pneumonia and no specific code forthat particular bacterial organismcontinued on p. 4 Pneumonia coding4a self-audit is a good place to start. In brief, you shouldperform self-audits until you are reasonably satisfied thatyou are in compliance with the laws and education should be multi-faceted.