All Entries Tagged With: "POA"
HACs set for October 1: Are you ready?
When a hospital-acquired-condition (HAC) is not present on admission (POA), and it is the only complication/comorbidity (CC) or major CC (MCC) on the claim, the case will group to a lower-weighted Medicare Severity DRG (MS-DRG). That means less reimbursement for your hospital.
“It could have a financial impact on the hospital’s bottom line,” says DeAnne W. Bloomquist, RHIT, CCS, a coding and compliance consultant and the president of Mid-Continent Coding, Inc., in Overland Park, KS.
The following eight HAC conditions take effect October 1:
- Foreign object retained after surgery. Codes 998.4 (foreign body accidentally left during a procedure) and 998.7 (acute reaction to a foreign substance accidentally left during a procedure) denote this HAC.
- Air embolism. Code 999.1 (air embolism to any site, following infusion, perfusion, or transfusion) denotes this HAC that refers to a condition in which air inadvertently passes through an open blood vessel.
- Blood incompatibility. Code 999.6 (ABO incompatibility reaction) denotes this HAC.
- Stages III and IV (decubitus) pressure ulcers. Code 707.23 indicates a stage III decubitus ulcer, and code 707.24 indicates a stage IV decubitus ulcer.
- Falls and trauma. This includes fractures, dislocations, intracranial injuries, crushing injuries, and burns. The following codes denote this HAC:
- Codes 800–829: Fractures
- Codes 830–839: Dislocations
- Codes 850-854: Intracranial injuries
- Codes 925–929: Crushing injuries
- Codes 940–949: Burns
- Codes 991–994: External causes (i.e., heat, air pressure, light, frostbite)
- Catheter-associated urinary tract infections (UTI). Code 996.64 (infection due to indwelling urinary catheter) denotes this HAC.
- Vascular catheter-associated infections. Code 999.31 (infection due to central venous catheter—catheter-related bloodstream infection, not otherwise specified) denotes this HAC.
- Mediastinitis after coronary artery bypass graft (CABG). Code 519.2 (mediastinitis) and a CABG procedure code from the 36.10–36.19 range denote this HAC.
For more information on HACs, visit www.cms.hhs.gov
To listen to the HCPro, Inc., audio conference “POA Reporting for Hospital Acquired Conditions: Strategies to Obtain Complete Documentation,” visit www.hcmarketplace.com.
To read the complete article ” Don’t let HACs cut into your bottom line“, visit the ACDIS Web site’s Helpful Resources section.
Query tip for principal diagnosis of fall admissions
by Joel Moorhead, MD, PhD
An article from the Journal of Trauma in 2006 documented that there are more than 770,000 yearly hospital admissions after falls—45% of all hospital admissions for trauma. A fall is surely the most common principal diagnosis that presents coding problems—even when there is clear physician documentation.
Attending physicians sometimes document ‘fall’ as a principal diagnosis but do not identify any specific cause(s) for that fall. However, coders cannot assign a code for a principal diagnosis without knowing what caused the fall, so keep these guidelines in mind:
- Select a principal diagnosis from established conditions the physician has clearly documented.
- Query the physician to obtain a principal diagnosis when documentation is not explicit.
Then, when querying a physician for more detail keep in mind a number of important factors. Falls are often multifactorial, due in equal measure to more than one established condition. When multiple conditions are eligible candidates for principal diagnosis, ICD-9 coding guidelines are clear that coders can sequence any of them as the principal diagnosis. However, when appropriate, ask the physician to clarify whether the documented causes equally contributed to the fall or whether one of the established causes is the principal diagnosis.
Nevertheless, the physician may not know the answer to the query. He or she may not know how that patient fell and received his or her injuries. So provide the physician an opportunity to say that he or she is unable to determine the answer to the query. This guideline is problematic when the coder cannot assign a code for the principal diagnosis directly from physician documentation. A coder’s health information management department may have a policy on whether or not to include an ‘unable to determine’ response option in queries for a principal diagnosis.
When a physician doesn’t reply to a query despite respectful encouragement, review the medical record carefully to determine whether the existing documentation sufficiently supports any established condition as the principal diagnosis.
Editor’s note: This post was adapted from our sister publication JustCoding.com. Joel Moorhead, MD, PhD is an adjunct assistant professor at the Rollins School of Public Health at Emory University in Atlanta. He is also a physician reviewer for FairCode Associates in Towson, MD. E-mail him at jmoorhe@sph.emory.edu.
CDI implications included in IPPS proposed rule
The long-awaited fiscal year (FY) 2010 Inpatient Prospective Payment System (IPPS) proposed rule is out, and with it comes good and bad news for hospitals. Hospitals will see historically low payment updates with a phased-in documentation and coding adjustment (DCA) to take place over time.
The proposed update for acute care hospitals means an update of 2.1% for inflation minus a DCA of 1.9 percentage points. Long-term care hospitals will see a proposed update of 2.4% for inflation minus a DCA of 1.8 percentage points. These DCA adjustments reflect the differences between the changes in documentation and coding that do not reflect real changes in case-mix for discharges occurring during FY 2008, according to CMS.
These low rates won’t help hospitals struggling to keep their doors open in the midst of a worsening economy. “Hospitals that are counting on some sort of increase won’t really see anything this year,” says Kimberly Hoy, JD, CPC, director of Medicare compliance for HCPro, Inc. in Marblehead, MA. “Payments are going to stay flat, and that’s going to be tough for a lot of hospitals.”
Clinical documentation improvement programs as well as more diligent efforts by HIM are most likely the reasons behind more accurate coding that led to higher payments, agrees Shannon McCall, RHIA, CCS, CCS-P, CPC-I, director of HIM and coding for HCPro, Inc. in Marblehead, MA.
“CMS may have underestimated that facilities would create such effective clinical documentation improvement programs,” she says. “I think those programs were an integral part of all of this.”
And in light of decreased payment updates, hospitals that don’t currently have a clinical documentation program will need to think seriously about implementing one, says Gloryanne Bryant, RHIA, CCS, CHW senior director of corporate coding and HIM compliance in San Francisco.
“Hospitals will need to assess their current efforts to capture patient severity and acuity through documentation and coding to see if opportunities remain,” she says.
Questions from Brian’s Mailbox
Brian Murphy (our beloved ACDIS Director) routinely gets loads of e-mail and as much as he would love to be able to answer each message or question personally, the sheer volume can be overwhelming. So…he’s tossed a few questions my way and asked if I could address them.
The following are a few questions from his “in-box”:
Q: Should we document verbal queries in the record? Should we include paper queries in the record?
A: This is a matter for your facility to decide with collaboration from the CDS, HIM, and compliance departments. Let’s see what AHIMA had to say about this issue in the recently revised query brief Managing an Effective Query Process:
“Permanence and retention of the completed query form should be addressed in the healthcare entity’s policy, taking into account applicable state and quality improvement organization guidelines. The policy should specify whether the completed query will be a permanent part of the patient’s health record. If it will not be considered a permanent part of the patient’s health record (e.g., it might be considered a separate business record for the purpose of auditing, monitoring, and compliance), it is not subject to health record retention guidelines.”
So, there’s no hard and fast rule about this. Our facility does both. First, I’ll address the second part of the above question.
Pressure Ulcer Coding and Staging
Does it sometimes seem like wound and pressure ulcer documentation is a movable feast? I’ve spent a lot of time scrutinizing wound documentation lately in anticipation of the new pressure ulcer codes being implemented October 1st and sometimes I can hardly believe what I’m seeing.
I’ve seen wound care flow sheets where vascular or diabetic ulcers are incorrectly documented with a stage (which should only be assigned to pressure ulcers) and I’ve seen pressure ulcers go from stage I to stage III or from stage III to stage I between one shift and the next. [more]
POA: Episode II
Preface to the following: You won’t find a more staunch advocate for ethical behavior in the documentation compliance profession than me. I firmly believe that documentation compliance is all about quality, specificity, and the behaviors and processes that support those aims.
However, we all also know that when it comes to implementing new initiatives it’s the bottom line that makes the decisions. That being said…
Once upon a time in a galaxy far, far away there existed an entity known as CMS, sometimes called the Empire. The Empire controlled everything in its purvue, including hospital reimbursement.
Last year the Empire passed a new law called “Present on Admission (POA)”. All the citizens who reported to the Empire lived in fear of this new law but the first year passed without any significant battles.
Episode 2:
I suspected (as I’m sure you all did) that once the Empire announced that it would exclude payment for hospital-acquired conditions, it was only a matter of time before the commercial carriers followed suit. Guess what? It happened.
Welcome to CDI Blog
I’m honored to be asked to write the first post for our soon-to-be-famous CDI Blog! There are so many wonderful people involved with the ACDIS, many whom I’ve met over the phone and many over the internet. The internet is really a great tool: it allows us to communicate instantly and directly with one or many, share our ideas and it’s a wonderful venue for building our community: that of Clinical Documentation Specialists.
What we do is hard to explain to outsiders. It involves the ability to read a patient’s chart, understand their diagnosis and treatment plan and to identify whether the documentation in the record, once translated into ICD-9 codes, will paint an accurate picture of their inpatient stay. Our efforts impact a facility’s public quality ratings, affect physician profiles, and determine the revenue a hospital receives. [more]