All Entries in the "Coding" Category

ACDIS advises members to ‘stay the course’ despite potential ICD-10 delay

ACDIS Advisory Board recommend facilities continue with ICD-10 preparations.

As I’m sure most of you are aware, The Department of Health and Human Services (HHS) has proposed a one-year delay of ICD-10-CM and ICD-10-PCS. You can read the complete release here http://www.gpo.gov/fdsys/pkg/FR-2012-04-17/pdf/2012-8718.pdf. The go-live date for which most of us were preparing—October 1, 2013—is now extended to October 1, 2014, barring any last-moment changes.

According to CMS, many provider groups had expressed serious concerns about their ability to meet the initial Oct. 1, 2013 compliance date. The proposed change in the compliance date for ICD-10 will give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition to these new code sets.

ACDIS would like to offer the following guidance for our members:

Stay the course with ICD-9 and ICD-10 documentation education. Hospitals continue to struggle with documentation and coding requirements under ICD-9; the best way to prepare for ICD-10 is to perform ICD-9 correctly and negotiate the differences between it and the new coding system. Regarding the best time to begin ICD-10 training: We’ve heard anecdotal evidence of hospitals moving out their ICD-10 training dates for their coding staff, which is understandable. However, an industry-wide recommended first step is ensuring that additional required physician documentation is in place for HIM/coding staff. Getting the additional specificity necessary under ICD-10 now is a good way to ensure a seamless transition to October 1, 2014. CDI specialists should use this time to improve their core competencies and knowledge base of ICD-10.

Provide commentary to CMS. Commentary on the proposed rule is open for 30 days starting on Tuesday, April 17. If you feel strongly that the one-year delay should not be implemented, or if you believe that the one-year delay will benefit your hospital, let CMS know by providing your comments at regulations.gov. CMS reviews all provider comments, and who better to hear from than CDI specialists, for whom the change to ICD-10 will be of the greatest impact. To comment on the proposed delay to ICD-10, click the following link to the Federal Register http://www.regulations.gov/#!documentDetail;D=CMS-2012-0043-0001 and click the “Submit a Comment” button. Comments are due on May 17, 2012 by 11:59 p.m. ET.

Brian Murphy, ACDIS Director, and the ACDIS Advisory Board

CMS issues IPPS proposed rule for FY 2013

CMS released the 2013 IPPS proposed rule Tuesday night.

by Michelle A. Leppert, CPC-A

Inpatient acute care hospitals could see a 2.3% increase in payment rates under the fiscal year (FY) 2013 Inpatient Prospective Payment System (IPPS) proposed rule, released April 24. The 2.3% is a net update after inflation, due to improvements in productivity, a statutory adjustment factor, and adjustments for hospital documentation and coding changes.

In addition, the IPPS proposed rule contains provisions to strengthen the Hospital Inpatient Quality Reporting (IQR) Program and proposes new policies and measures for the Hospital Value-Based Purchasing (VBP) Program.

“If the goal is to reward excellence, hospitals have to ensure that their coders are up to speed with appropriate identification of complications and with [present on admission] POA indicators as well as the over-documentation issues that could lead to financial penalties,” says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.

CMS also proposes a methodology to calculate the readmissions adjustment factor for inpatient hospitals that could result in a 0.3% decrease in overall payments to hospitals.

Coding changes
As expected, there were few changes to the ICD-9-CM code set. CMS previously indicated that it would limit such changes to allow providers time to prepare for ICD-10 implementation previously slated for October of 2013 but now potentially delayed until October of 2014.

“Since we are proposing to use ICD-9-CM until October 1, 2014, it potentially adds another year of limited updates,” says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding for HCPro, Inc, in Danvers, Mass.

For FY 2013, CMS proposes to reassign cases with a principal diagnosis code 487.0 (influenza with pneumonia) and a one of a list of pneumonia codes listed as a secondary diagnosis codes from MS-DRGs 193, 194, and 195 to MS-DRGs 177, 178, and 179. CMS proposes to make three additional codes complications and comorbities (CCs) and change one major CC (MCC) to a CC for FY 2013. It does not plan to add any MCCs or delete any CCs.

CMS proposes adding these diagnoses to the CC list:

• 263.0, Malnutrition of moderate degree
• 263.1, Malnutrition of mild degree
• 440.4, Chronic total occlusion of artery of the extremities

It also is proposing to change the severity level of diagnosis code 584.8 (acute kidney failure with other specified pathological lesion in kidney) from an MCC to a CC.

“While I support many of their CC/MCC changes, such as making mild and moderate malnutrition a CC, I am saddened that CMS still refuses to make heart failure not otherwise specified a CC,” says James S. Kennedy, M.D., C.C.S., C.D.I.P., managing director at FTI Consulting in Brentwood, Tenn.

IQR proposed changes
The IQR program currently includes 72 quality measures. CMS has proposed reducing that number to 59 for the FY 2015 payment determination, and 60 for the FY 2016 payment determination.

Participation in the IQR program is optional, although those who choose not to participate receive a 2% reduction in the annual payment update. CMS proposes adding perinatal care and readmissions, including overall readmissions and readmissions relating to hip and knee replacement procedures to the IQR quality measures for FY 2013. In addition, CMS would also measure how well hospitals use a surgery checklist designed to reduce errors.

VBP proposed changes
Beginning in FY 2013 and continuing annually, CMS will adjust hospital payments based on how hospitals perform or improve their performance on a set of quality measures.

For the FY 2014 VBP Program, the proposed rule includes a new outcome measure that rewards hospitals for avoiding central line-associated bloodstream infections that can develop during inpatient hospital stays.

For the FY 2015 VBP Program, CMS proposes grouping and scoring measures in four domains—clinical process of care, patient experience of care, outcome, and efficiency. CMS also proposes adding a total of four new measures to the list.

Readmissions reduction program methodology
In the FY 2012 IPPS final rule, CMS began implementation of the Readmissions Reduction Program for three conditions:

1. acute myocardial infarction (i.e., heart attack)
2. heart failure
3. pneumonia

CMS also finalized its definition of readmission as:

“occurring when a patient is discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period [30 days] from the time of discharge from the index hospitalization.”

CMS also addresses these areas related to the program:

• Adjustment factor (both the ratio and floor adjustment factor)
• Aggregate payments for excess readmissions and aggregate payments for all discharges
• Applicable hospital
• Limitations on review
• Reporting of hospital-specific information, including the process for hospitals to review and submit corrections

Additions to the HAC list
CMS proposes adding two conditions to the list of hospital acquired conditions (HACs) for 2013:

1. surgical site infection following cardiac implantable electronic device (CIED)
2. iatrogenic pneumothorax with venous catheterization

Inpatient facilities do not receive higher MS-DRG payments for patients with complications or major complications caused by the conditions on the HAC list. CMS plan to update the existing vascular catheter-associated infection HAC category by adding the following two codes:

1. 999.32 (bloodstream infection due to central catheter)
2. 999.33 (local infection due to central venous catheter)

CMS proposed adding pneumothorax associated with transbronchial biopsy several years ago, but it was not finalized, McCall says. This condition does seem to meet HAC the criteria of occurring commonly and can cause a significant increase in resource consumption in order to treat this condition, she says. It is also labeled as a complication and comorbidity. However, HACs must also be reasonably preventable, according to evidence-based research, and this has also kept other conditions, such as ventilator-associated pneumonia, off the list in the past.

The addition of the surgical site infections from CIEDs seems to follow along with the inclusion of other site infections already on the HAC list, especially given an increased focus on ensuring sterile environments to avoid contamination of a primary infection at the time of placement of such devices, McCall says.

Coding and documentation adjustment
CMS expects the FY 2013 proposed documentation and coding adjustment (DCA) to net an aggregate increase of 0.2%. The DCA was originally established at the time CMS implemented MS-DRGs. It was thought that due to the increased need for specificity, facilities would focus attention on improvements to documentation. The last two years, the DCA has resulted in a payment offset of -2.0% and -2.9%.

“In good news, the documentation and coding adjustment actually works in the provider’s favor this year, increasing reimbursement by 0.2%,” Kennedy says. “That’s a substantial increase from the previous years.”

Comment on the proposed rule
CMS will accept comments on the proposed rule until June 25 and will respond to all comments in a final rule to be issued by August 1, 2012. Facilities can download a display copy of the proposed rule here.

The proposed rule will appear in the May 11, 2012 Federal Register.

Editor’s Note: This article first appeared as a “Breaking News Alert” and was published on HCPro.com.

Book Excerpt: Coding guidelines for diabetes under ICD-10

The age of a patient is not the sole determining factor for the type of diabetes, although most Type 1 diabetics develop the condition before reaching puberty. For this reason, Type 1 diabetes mellitus is also referred to as juvenile diabetes. If the physician does not document the type of diabetes mellitus in the medical record, the default category of codes is E11 (type 2 diabetes mellitus).

If the physician does not document the type of diabetes but does indicate that the patient uses insulin, assign a code from category E11; also report code Z79.4, long term (current use insulin to indicate that the patient uses insulin. Do not report code Z79.4 if a Type 2 patient is given insulin temporarily to bring  his or her blood sugar under control during an encounter. In situations where diabetes occurs during pregnancy and for cases of gestational diabetes, refer to the ICD-10 Official Guidelines for Coding and Reporting Section I.C.15, Diabetes mellitus in pregnancy and gestational (pregnancy-induced) diabetes.

The codes under category E08 (diabetes mellitus due to underlying condition) and E09 (drug or chemical induced diabetes mellitus) identify complications/manifestations associated with secondary diabetes mellitus. Secondary diabetes is always caused by another condition of event (e.g., cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drugs, poisoning.)

The sequencing of the secondary diabetes codes in relation to codes for the cause of the diabetes is based on the tabular instructions for categories E08 and E09. For category E08, first code the underlying condition. For category E09 first code the drug or chemical (T36-T65). For a patient with diabetes ketoacidosis without coma due to cirrhosis of pancreas, report K86.8 (cirrhosis of pancreas) and E08.10 (diabetes mellitus due to underlying condition with ketoacidosis without coma).

Editor’s Note: This post is an excerpt from The Clinical Documentation Improvement Specialist’s Guide to ICD-10.

Words to clarify by

Use these common phrases as clues for further investigation.

Many novice CDI specialists do not readily identify when a diagnosis needs clarification. The following list is intended to serve a gentle reminder to “dig deeper.” Here is a list of “clue” words to help you identify when a query may be needed for clarification or specificity.

AMS needs clarification as to possible Acute Confusional State, Alzheimer’s Dementia, or Alzheimer’s with Behavioral Disturbance. If with associated Infection, metabolic condition, etc. it could also indicate Encephalopathy.

Urosepsis could be UTI or Sepsis secondary to UTI.

Hypoxemia/Respiratory Insufficiency could indicate a diagnosis of Acute Respiratory Failure or Acute post Operative Respiratory Insufficiency if the indicators are present. (E.g. Use of C-pap or Non re-breather mask, or O2 saturation less than 92%).

Anemia requires specificity of Chronic Anemia, Acute Blood Loss Anemia, Aplastic Anemia, etc.

Renal insufficiency/chronic kidney disease (CKD) requires added specificity for the stage of the CKD, the Creatinine baseline and further specificity as to possible Acute Renal Failure (ARF), and if indicators present (E.g. nephrotoxic medication usage) ARF with Tubular Necrosis.

FTT, Anorexia may indicate Malnutrition. If present, further specify as to whether it is mild, moderate, or severe.

CHF requires specificity of acute or chronic and systolic or diastolic heart failure.

Right/left sided weakness may indicate a diagnosis of hemiplegia or hemiparesis.

Problems with speech post CVA may indicate a diagnosis of Aphasia.

Drug use History requires clarification of use or abuse and if the Drug Use/Abuse is Ongoing.

Abdominal pain requires documentation of an underlying diagnosis. (E.g. Ulcer, Acute Pancreatitis, etc)

Chest pain requires documentation of an underlying diagnosis. (E.g. CAD, Angina, Costochondritis, etc.)

Gangrene-requires further specificity as to “Wet” infectious or “Dry” ischemic Gangrene

Poorly controlled Diabetes needs clarification whether Uncontrolled or Controlled Diabetes Mellitus.

Hypertensive Emergency needs clarification as to Malignant or Accelerated Hypertension.

DVT needs clarification as to Deep Vein Thrombosis or Thrombophelbitis.

I&D needs clarification as to whether this means Irrigation and Drainage, Exisional Debridement or Non Exisional debridement. (If exisional debridement performed then documentation must state if scalpel was used, clear margins obtained, and depth up to and including deepest layer.)

↓↑Na is not a diagnosis. Documentation must be obtained as to possible Hyper/ Hyponatremia.

Incorporate awareness of transfer DRGs into CDI record review efforts

CMS never met a dollar it didn't want back.

CMS never met a dollar it didn’t try to recoup. So we have RACs and HACs and stacks of regulatory requirements that take many, many healthcare dollars to manage. The post-acute care transfer DRGs are but one example.

(RACs, of course, are Recovery Audit Contractors which the government recently renamed Recovery Auditors or the Recovery Audit Program. And I’m sure you all know that HACs stands for hospital acquired conditions.)

For the uninitiated, post-acute care transfer DRGs exist because CMS doesn’t want to pay the hospital the full freight if the patient receives follow-up care somewhere else, and it ends up having to pay the another facility or healthcare agency (such as home health) as well. When the program began, 10 DRGs were designated as transfer DRGs; that list has since expanded to 273.

You can download the current list here.

Why do you need to know about transfer DRGs?

The CDI specialist is one of the few people who has at least a general idea of where the DRG is going to land before the patient is discharged. As you know, every DRG is attached to both an arithmetic length of stay (A/LOS) and a geometric length of stay (G/LOS). The A/LOS is the average LOS of patients within that DRG, including transfers and long-stay outliers. The G/LOS is the national mean length of stay for that DRG, except for transfers and long-stay outliers. The A/LOS is used for calculating outlier payments, while the G/LOS determines the transfer DRG payments. If you don’t have a good idea of the DRG before you transfer the patient or discharge the patient with services, your facility’s number crunchers could have an unpleasant jolt at reimbursement time.

When a patient is transferred to another facility or home with services after staying fewer days than the transfer DRG’s G/LOS, the post-acute care transfer DRG rule kicks in. Instead of receiving the full DRG reimbursement (relative weight multiplied by the hospital’s blended rate), a per-diem rate applies. The per-diem rate is the DRG reimbursement divided by the G/LOS. The hospital will receive twice the per-diem rate on day one and the per-diem rate every day thereafter up to the full DRG reimbursement.

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Q&A: How to resolve DRG confusion

Q: Confession. I am very frustrated. I am fairly new to CDI. I have a nursing background. I’m trying to understand how

Learning how to navigate the coding and DRG landscape can be daunting. Don't worry. Others have had to learn this too. Ask for help and know you are in good company.

the coding and DRG system works. But when I look up a diagnosis in the DRG Expert in the alphabetic index to diseases it is not listed as I would expect it to be.

Take for example, bradycardia. It is not listed under that term or arrhythmia.  Yet, it is listed under cardiac arrhythmia. For another example, how about anorexia? The only listing is anorexia nervosa—not unspecified.

I also find it ironic that I cannot infer what a physician is stating (it has to be documented precisely) but when I have to look up a term I have to guess its meaning.

Do you have any advice for me?

A: Your frustration is very common among new clinical documentation improvement (CDI) specialists.  The publishers of the DRG Expert did not include the same type of Index to Diseases that you would find in Volume I of an ICD-9 code book—probably to save space. The Index to Diseases alone in my code book is 380+ pages.

This is one reason that during the CDI BootCamp I mention so many diagnoses as we review Medicare Severity Diagnosis-related groups (MS-DRGs) in a major diagnostic category (MDC) and either have you highlight them or write them in, because I, too, had exactly the same issues you are having.

Every CDI team should also have a coding book in their department to use as a reference (ask your facility HIM department if they have an old one you can have), especially if you do not have access to the encoder (coding and reimbursement software), which would let you look up whatever you wanted—however, even that has limitations, because search terms often use “coding language” rather than the everyday language of clinicians.

As far as your comment regarding the irony of the situation, all I can say is “Right on, girl!”  It is the reason we have taken on this role. We were hired to become the “translators” or “interpreters” to ensure that the clinical language matches the language needed by the coders. Acquiring the skills to understand both of these languages, along with the ability to translate from one to the other, is what makes us, as CDI professionals, unique.

As a final note, I just want to share that my very first DRG Expert was COVERED from end to end with handwritten notes, stickies, and slips of paper. I used this book for three years, copying my info into each new edition until I was granted encoder access. Every time I asked a coder where to find something I wrote it in the book—especially those diagnoses that had really strange “code” descriptions.

I hope that I can assure you, that by this time next year, you will have many of these coding terms memorized.

I tell all my CDI BootCamp students that there is a long learning curve to this position, so don’t worry. While some people catch on quickly, for most it may take up to six months before that proverbial light bulb finally goes on and frequently it takes up to a year to feel confident in the role.

Don’t get discouraged. Most CDI specialists will tell you the same thing! Before you know it, you will find yourself sitting in traffic, converting license plate numbers into DRGs or diagnosis codes.

Q&A: Choosing the most appropriate principal diagnosis

Q: A 79-year-old male nursing home patient presents with lethargy, confusion, and fever after failing an

Discerning the principal diagnosis is difficult at best.

outpatient course of Bactrim for a suspected urinary tract infection (UTI). His white blood count is 22,000, segs 85, bands 10, and blood cultures are negative. He has a temperature of 102°, his blood pressure is 94/60.

His urine is cloudy and brown. A bolus of fluid is given in the emergency room (ER) with subsequent dramatic improvement in the patient’s mental status. The ER physician admits the patient for “fever workup and UTI” and documents urosepsis. Patient is treated with IV antibiotics, Tylenol, and continued IV fluids.

Given the rule of “when a symptom is followed by contrasting /a comparative diagnosis, the symptom code is sequenced first,” should the principal diagnosis be fever with the UTI as the MCC/CC?

A: The provider documentation said “fever workup and UTI.” “Fever workup” is just a comment about what is planned, not a diagnosis. In addition “fever” is a symptom code and coding guidelines state that a symptom should not be sequenced as the principal diagnosis when a definitive diagnosis is known. In this case, “urosepsis”—which has been documented, is a diagnosis (599.0—the same code as UTI).

If you were to go ahead and code the fever the code would be 780.61, Fever presenting with conditions classified elsewhere. However, any code from the 780 range is considered a symptom, another clue to look elsewhere for the principal diagnosis. If you were to look up 780.61 in the code book here is what you’d find:

780.61, Fever presenting with conditions classified elsewhere

Code first underlying condition when associated fever is present, such as with:

leukemia (codes from categories 204-208)

neutropenia (288.00-288.09)

sickle-cell disease (282.60-282.69)

The phrase “code first” means that you would first code the condition/disease causing the fever and a few examples, not the complete list, are provided.  In other words, due to the coding direction “code first” this code (780.61) could never be the first-listed or principal diagnosis. So, here’s how the scenario plays out:

• Principal diagnosis: UTI
• Procedure: None
• MCC/CC: None
• MS-DRG Assignment:  MS-DRG 690, UTI without MCC
• Query opportunity? Yes. Query the physician to clarify the term “urosepsis.” There won’t be a code for urosepsis in ICD-10 so start making this diagnosis an educational priority, if you haven’t done so already.  You would want to ask the physician (if appropriate) if he/she is treating the patient for a localized infection (urosepsis/UTI) or a systemic infection (sepsis due to a urinary tract infection or from a urinary source).
  Before you query, investigate the clues of failed outpatient antibiotics, hypotension, and altered mental status.  Evaluate additional lab results, assess how “sick” the patient is and include that information in your query.  The scenario above stated that the patient’s mental status improved with hydration, so I wouldn’t necessarily jump on the “sepsis” bandwagon. And although the blood pressure appears somewhat low, this may be within normal parameters for this patient. Assess what this patient’s baseline is, a very important step prior to querying for any diagnosis.
• Query/potential DRG (only if the patient meets clinical parameters and the documentation and treatment plan support the diagnosis): DRG 872, Sepsis with UTI as a secondary diagnosis

Editor’s Note: Lynne Spryszak, RN, CCDS, CPC-A, AHIMA-Approved ICD-10 CM/PCS Trainer, CDI Education Director for HCPro Inc., in Danvers, MA, answered this question. Contact her at lspryszak@hcpro.com.

Clarification regarding Coding Clinic publication

The AHA will begin to collect and respond to limited questions regarding the ICD-10 code set.

The American Hospital Association (AHA) has not made any formal decisions regarding when it will begin publishing a separate Coding Clinic for ICD-10, contrary to what was reported in December 1 edition of CDI Strategies, according to Nelly Leon-Chisen, RHIA, director of coding and classification for the AHA.

Those with questions pertaining to ICD-10 can submit them to the AHA now. Those who submit inquiries must have working knowledge of the new code set and questions must pertain to the application of the codes and the interpretation of the medical record.

The AHA is beginning to collect questions regarding the new code set and will include some of those questions starting with its 4th Quarter 2012 edition of Coding Clinic for ICD-9-CM, Leon-Chisen told ACDIS.

“This service is for coding advice only not for advice about ICD-10 implementation,” Leon-Chisen said during CMS’ “ICD-10 Implementation Strategies and Planning National Provider Call” on November 17.

The AHA has no plans to translate guidance from previous volumes of Coding Clinic for ICD-9-CM, as the increased specificity of the new code set is expected to make much of the guidance obsolete. However, it has not made a decision just yet about when it will stop publishing Coding Clinic for ICD-9-CM, or when it might begin publishing a specific Coding Clinic for the new code set.

Pediatric reviews: Know the rules before you play the game

by Robert S. Gold, MD

Even experienced and consistently accurate acute care hospital coders may not be familiar with pediatric

Don't throw the baby out with the proverbial bathwater when it comes to documentation and coding improvement associated with pediatrics.

diseases. Age is not a factor for some conditions (e.g., appendicitis). Others are age-specific or have age-specific diagnosis, healing, and treatment implications. Coders must consider this when assigning codes and querying physicians.

Consider a Colles’ fracture. It occurs in both children and adults, but the healing process is different because of the growth plates in the pediatric population. Aspiration pneumonia can present in both groups, but the cause may differ anatomically and microbiologically. Bronchospasm in adults likely has a completely different cause than in children. Diabetes may have similar long-term outcomes, but type 1diabetes is more difficult to manage psychosocially than type 2 in the pediatric population.

Numerous examples illustrate the differences between pediatric and adult diseases. Bacterial causes of pneumonia differ based on age group. Cerebral hemorrhage may have the same fatal outcome in children and adults, but rarely the same cause. Physicians must approach causes of respiratory distress in children quite differently. Heart failure is completely different in the two groups. Even the types of cancers that occur in children are different.

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A peck of PEPPER, Part 3

Sort through your PEPPER reports to find additional query opportunities.

If you’ve started using your PEPPER to help you identify potential issues at your hospital, good for you!  In this final entry, I’m going to suggest you take it a step further—identifying charts that may fail for lack of medical necessity.

I’m pretty sure that a RAC bounty hunter will jump at the chance to overturn your admissions due to not meeting criteria.  Nobody’s expecting you to become a case manager, but it  behooves all of us to gain an understanding of what documentation may survive a medical necessity audit.

Quite a few of the PEPPER medical necessity target areas involve what might be considered questionable diagnoses—including our old favorites, chest pain, TIA, back pain, and syncope—and some others that you might not have thought of as questionable, such as DRG 314-316 and DRG 393-395, as well as short stays in renal failure, vascular surgery, and heart failure DRGs.  If you are a high outlier, review your short stay patients, to see if their documentation supports an inpatient stay.

InterQual(TM) guidelines now include the condition-specific diagnoses of acute coronary syndrome (ACS), asthma, epilepsy, heart failure, pneumonia, and stroke/TIA, with plans to add many more.   The new guidelines help you determine who qualifies for inpatient and who should stay in an observation status.  If you don’t have access to admission and continued stay criteria, make friends with someone who does, or better yet, ask your manager to give you access and send you to class to learn the basics.  (Some hospitals use Milliman (TM) guidelines, so your mileage may vary.)

Your impact will be on documentation that supports inpatient severity of illness.   The physician admitting a patient for acute onset chest pain or suspected MI needs to understand the importance of documenting a specific diagnosis such as acute MI supported by positive cardiac markers, or unstable angina, any EKG changes that support the diagnosis, and following specific treatment protocols.

It’s not enough for a physician to diagnose pneumonia in a stable patient—the treatment on day one is the same for both observation and acute inpatient status so the difference is in the presentation, and that means documentation.  What is the oxygen saturation?  Did the patient fail outpatient antibiotics?  Is there evidence of abscess or empyema?  Is the pneumonia multilobar?  Are there additional clinical risk factors?

For your TIA patients, a TIA lasting longer than 60 minutes raises the likelihood of meeting inpatient criteria.  Teach your physicians to assess and document the duration of TIA symptoms.  “R/O stroke” won’t allow you to work around TIA, without documentation of specific physical findings consistent with a possible stroke, such as paresis or dysphagia, or confirmation of CVA by CT or MRI.  For your stable heart failure patients, among the requirements for an acute inpatient admission is oxygen saturation below 89% or a sustained heart rate of 100-120 bpm within 24 hours of admission.  Evidence of greater instability, such as hypotension, mental status changes, or heart rate > 120, with IV medications or increased oxygen requirements, may move the patient into an intermediate or critical care status.

In DRG 314 – 316, other circulatory system diagnoses, you might have patients who come back with a vascular complication such as an occluded central line.  Just having a complication is not enough to justify an inpatient stay—is there evidence of a decreased peripheral or femoral pulse?  Did they qualify for an inpatient admission in some other way?  Syncope, DRG 312, may meet inpatient criteria if it is attributed to a cardiovascular drug, reflects evidence of certain arrhythmias or pacemaker failure, or if the patient has known cardiac disease.  Do you see a documentation opportunity there?

Look closely at your short-stay patients, regardless of DRG.  Did they meet criteria because they underwent a procedure on the inpatient list?  Or did the physician not really think about admission status when they wrote the order? Your PEPPER will list your top medical DRGs for one-day stays.  Consider auditing the top DRGs, particularly if they are the non-specific DRGs such as chest pain and syncope, for medical necessity.  Can the top DRGs be explained by a specific patient population your hospital services?  Did the documentation support the status order?  Did the patient leave before the case manager had a chance to review the case?  Does your CM department just do a great job of moving patients through the system?  What processes does your hospital have in place for reviewing short-stays, either concurrently or retroactively?  What documentation improvement processes can you recommend and/or implement?

I was trying to think of some snappy way to join SALT with PEPPER, but all I came up with was the strategic arms limitation talks.   So on that note, don’t try to force documentation to fit when it doesn’t.  But the more you know, the more you can do.