May 9, 2013

Commonwealth of Virginia Department of MedicalAssistance Services Division of Program Integrity

A Presentation to the Virginia Health Information Management Association (VHIMA)

VA DRG Audit Contract

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AGENDA • Summary of Audit Project

– Overview of the VA DRG Audit Program– Sample Letters– Category of Errors– Trending – DRG Coding Errors– Septicemia– Pneumonia– MCCs and CCs– Acute Renal Failure– Acute Respiratory Failure– Kwashiorkor– Other Problem Areas– Provider Responses– Questions

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Overview of the VA DRG Audit Program• Summary of Medical Record Review

– Currently in the 6th Contract Year• 7.5% of all DRG claims selected for review• 90% targeted sample• 10% random sample

– AP DRG version 25.1 (beginning 7/1/2010)

• Process– Medical Record Request

– 30 days to submit medical records

– Preliminary Findings Letters– 30 days to submit additional documentation

– Final Findings Letters– 30 days to file an informal appeal

– Appeal Process

Sample Preliminary Findings Letter

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Sample Final Denial Letter

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Category of ErrorsVA Medicaid Utilization Review Program

Contract Year 5 - Review Results

Completed Reviews 5,267

Cases with Errors 696 13.2%

Category of ErrorsNumber

with Errors %

DRG Reassignment 414 59.5%

Billing—ReadmissionsDischarged and returns to the same hospital within 5 days with the same or similar diagnosis

117 16.8%

Billing—Transfer BillingDischarged and admitted to another hospital within 5 days with the same or similar diagnosis

65 9.3%

Billing Errors—OthersProvider billed for DRG payment even though order was for outpatient or observation level of care

78 11.2%

Technical Denial 22 3.2%

Total 696

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Trending—DRG Coding ErrorsVA Medicaid Utilization Review Program

Contract Year 5 - Review Results

Top DRGs – Among Claims with Errors

DRG DRG Name Number

Percent ofAll Claimswith Errors

584 SEPTICEMIA WITH MAJOR CC 54 7.7%

566 ENDOC,NUTRIT & METAB DISOR EXC EAT DISORD OR CF W MAJ CC 22 3.1%

089 SIMPLE PNEUMONIA & PLEURISY AGE >17 W CC 19 2.7%

468 EXTENSIVE OR PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 17 2.4%

087 PULMONARY EDEMA & RESPIRATORY FAILURE 17 2.4%

541RESPIRATORY DISORDER EXC INFECTIONS, BRONCHITIS, ASTHMA WITH MAJOR CC

15 2.1%

552DIGESTIVE SYS DISORDERS EXC ESOP, GAST & UNCOMP ULCERS WITH MAJOR CC

13 1.8%

540 RESPIRATORY INFECTIONS & INFLAMMATIONS WITH MAJOR CC 10 1.4%

543CIRC DISORDERS EXC AMI, ENDOCARDITIS, CHF & ARRHYT WITH MAJOR CC

10 1.4%

Total with Top DRGs 177 25.4%

Total Claims with Errors 696

The top 9 DRGs listed above account for 25.4%of all the claims with errors.

Septicemia• Diagnosis ruled out – especially in newborns/infants

– V29.0 Observation for suspected infectious condition

• Sequencing (cause of sepsis)– If acute respiratory failure is a result of sepsis, sepsis is coded

as the principal– If sepsis is the result of vascular catheters, or urinary catheters,

codes related to infection of these devices should be coded first.

• Clinical presentation and diagnostic testing• Definition: The presence of bacteria (bacteremia), other infectious organisms, or toxins created

by infectious organisms in the blood stream with spread throughout the body.– Systemic illness, patient is acutely ill, sepsis is not a random occurrence– Sepsis is more common in the elderly, individuals with a compromised immune

system and persons who are already acutely ill– Sepsis is often misused and misapplied to patients with fever, leukocytosis and

hypotension due to other causes– Documentation in medical record should be clear and consistent to support a

diagnosis of sepsis

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Pneumonia• Definition: An infection in one or both of the lungs. Can be caused by bacteria,

viruses or fungi. The infection inflames your lungs’ air sacs. The sacs fill up with fluid or pus causing symptoms such as a productive cough, fever, chills and difficulty breathing.

• Diagnostic Testing:– National Heart, Lung, and Blood Institute

• “A chest x-ray is the best test for diagnosing pneumonia”– Infectious Diseases Society of America/American Thoracic Society

Consensus Guidelines:• “In addition to a constellation of suggestive clinical features, a

demonstrable infiltrate by chest radiograph or other imaging technique, with or without supporting microbiological data, is required for the diagnosis of pneumonia”

• Red Flags:– Physician documents infiltrate on x-ray despite formal chest x-ray

report stating, “no infiltrates”– Physician documents pneumonia despite normal chest x-ray, normal

white count, etc.

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Major CCs and CCs

• Complications and Comorbidities (CC)• Major CCs

– CCs and Major CCs are diagnoses present on a case that significantly increase the expected resource consumption beyond that of the same case with no CCs or Major CCs

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Acute Renal Failure• Definition: A rapid decrease in renal function over days to weeks, causing an

accumulation of nitrogenous products in the blood (azotemia). In all cases, creatinine and urea build up in the blood, and fluid and electrolyte disorders develop.

• Diagnoses and Management– Mortality rate is 50-70% – 50% increase in creatinine above baseline– Treat underlying cause

• Red Flags:– Physician documents ARI; acute renal injury or acute renal

insufficiency– Individual has chronic renal failure and baseline creatinine is

not documented, and it is still elevated at discharge– Physician documentation inconsistent

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Acute Respiratory Failure• Definition: A syndrome in which the respiratory system fails in one of both of its

gas exchange functions: oxygenation and/or carbon dioxide elimination

• Acute respiratory failure can develop quickly and requires Emergency Treatment

– Individual presents with shortness of breath, rapid breathing, bluish color to skin, lips and fingernails, sleepiness and confusion

– Requires aggressive treatment (usually in the ICU)– Diagnostic Tests: Arterial Blood Gases

• Measures the oxygen and carbon dioxide levels in the blood• Need to diagnosis and treat underlying cause

• Red Flags:– Diagnostic testing and treatment not consistent with acute

respiratory failure (no ABGs, no increase in oxygen needs, etc)– Physical examinations state, “mild respiratory distress”– Physician documentation inconsistent between acute respiratory

failure and acute respiratory insufficiency/distress

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Kwashiorkor (260)• Definition: Syndrome, particularly of children; excessive carbohydrate

with inadequate protein intake, inhibited growth potential, anomalies in skin and hair pigmentation, edema and liver disease. Very rare in the United States

• “Protein Malnutrition”– ICD-9-CM book indexes this to code 260– However, it is described as “Nutritional edema with

dyspigmentation of skin and hair”– Coding Clinic Third Quarter 2009 states that it is not

appropriate to assign Kwashiorkor (260) if the provider does not specifically document this condition.

• “Protein-Calorie Malnutrition”– Codes to 263.x

• 260 is a major complication/comorbidity (MCC), 263 is a cc

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Other Problem Areas

• OR Procedure unrelated to principal diagnosis

– This occurs, but should be a rare event

• Ventilation DRGs– Ventilator substantiated? Hours on vent correct?

• Newborn birth weights• Excisional Debridement• Lysis of Adhesions

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Provider Responses• Provider stating the reassigned DRG is incorrect;

Provider did not use the AP Grouper• Stating, “I coded what the physician documented”

– Look for language in the denial letter stating, “Following Physician Review….”

• Stating what the physician “meant” without submitting the physician query, or a written statement by the physician

• Stating Prior Authorization obtained so should be DRG payment (even though no inpatient order or certification of need)

• Submission of a medical necessity response (HMS does not review for medical necessity)

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Questions

Kelly Dickson, RN, CFEProject Manager KDickson@hms.com(614) 839-3390