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 ..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.

2 Here s how to compare your data to that of other hospitals to determine risk shows lots of effort, few worries ..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. 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 ?

3 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).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. 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 .

4 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. When assigning codes for diagnoses addressedin the consultant s report, review all documentation tomake sure there is no contraindication from the attend-ing physician.

5 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. 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.

6 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. The samplebelow is from a PowerPoint presentation for physicianeducation on providing greater specificity in their doc-umentation. In summary, Coding professionals are to assign ICD-9-CM codes based onlyon physician documentationand should querywhen in s note: Bryant is director of Coding /HIM compli-ance at Catholic Healthcare West in San Francisco. Ifyou have questions or desire additional information,contact her at indexed in ICD-9-CM.

7 When a physician documentsbacterial Pneumonia without further specificity, you shouldassign ( Pneumonia , bacterial, unspecified).Self-auditing and educationIt is strongly recommended that hospitals perform self-audits as well as external audits on the pneumoniaDRGs to reduce the risk of noncompliance with lawsand regulations. More specifically, performing self-auditsat least once a year in areas that could pose a threat toyour facility is a good practice. These audits give youreasonable assurance that you are complying with gov-ernment regulations. Be familiar with your facility s coded data and auditwhen your statistics are out of the norm. A sample sizeof 50 records (depending on your facility volumes) forCoding pneumoniacontinued from p. 3 Physicians Improve your Profile!Document Clinical Specificity!Not Sure of the Cause? Probable Suspected Possible can bedocumented on inpatient records to showthe organism ( , Suspect Klebsiella or Probable gm neg.)

8 Pneumonia .) Apositive sputum culture is not required,for you to document the specific type ofpneumonia for are treating, for example: Gram neg. Pneumonia . This will helpreflect the severity and acuity of theillness and reflect the risk of Aspiration Pneumonia ?It can be documented as Probable Suspected Possible AspirationPneumonia. Contact the HIM/CodingDepartment for further 79 COMPLEXorDRG 89 SIMPLEP neumonia coding5 PHYSICIAN DOCUMENTATION QUERY SIMPLE VS COMPLEX PNEUMONIADear Dr: : _____Med. Rec. #: _____Documentation clarification is required to meet compliance, accuracy in codingand severity of illness reflection. Please respond to the query below on theprogress notes or as an addendum for your patient _____, there is documentation of Pneumonia in the medical record, clarification isneeded. Additional documentation is necessary to identify the organism or causativeagent of the Pneumonia , if known ( , pseudomonas, viral, aspiration, streptococcus,etc.

9 Please document, if known, the appropriate specific Pneumonia diagnosis on theprogress notes or on this form as an addendum. If the suspected cause is possible,probable, or suspected, please document as such. (Sign and date all documentation)_____(specific diagnosis/condition)_____MD Signature_____DateIf you have any Questions, please contact the HIM Department (Medical Records) at#_____. Thank YouNote: Negative or inconclusive sputum cultures do not preclude a diagnosis of a specific bacterial pneumoniain patients with the clinical evidence of this condition. (per: AHA Coding Clinic). If you are/were treating asuspected, possible or probable gram negative/positive Pneumonia or Sepsis, please document as you. **This form is a permanent part of the medical record**Sample physician document query formPneumonia coding6NJ hospital self-discloses Pneumonia Coding errorsThought the confusion over Coding and billing forpneumonia was over? With Hackensack (NJ) UniversityMedical Center s (HUMC) July 18 $ million fraud set-tlement, the issue has returned to the forefront of com-pliance concerns for many in 2000, HUMC self-disclosed its overbilling forMedicare inpatient Pneumonia cases from 1993 to DeMauro, MD,co-director of performance im-provement, says the settlement is the result of a misun-derstanding of highly complex government regulations.

10 The hospital had begun conducting audits, and routineclaims reviews of complementary diagnosis-related group(DRG) pairs identified a higher rate for more complexpneumonia cases. In a press release from the Attorney s Office, Districtof New Jersey, acting Attorney Ralph J. MarraJr.,says, A voluntary settlement is in the best interestsof the Medical Center and the United States. The Medi-care program receives the reimbursement it is owed,and a well-regarded medical center avoids potentiallyharsher sanctions. This is the kind of corporate behav-ior we want to encourage. We feel very fortunate that our own in-house monitoringpicked up on the problem and that corrective measureswere put in place to ensure that it will never happenagain, says DeMauro. The medical center is, and al-ways has been, committed to complying with all gov-ernment regulations on both a state and federal level,and especially in the area of Medicare benefits. As part of its compliance program, HUMC requirescontinuing education for both coders and physicians.