1. Unit 2 Overview Reading: Scott, Chapters 1, 2, and 3 Post to DB
(Doc sharing)
Post to DB
Participate in Option 1 or 2 of seminar
Practice:
Green Workbook: p. 52, questions 25 and 26
Writing Assignment:
Compare & contrast DRG system with MS- DRG system.

2. Unit 2 Overview Describe various payment methods.
Apply coding guidelines for proper payment under the Prospective Payment System (HI250-2)
Code and sequence, keeping in mind quality and reimbursement (HI250-2)
Utilize encoder and grouper software to code and assign an MS- DRG (HI250-4)

3. Inpatient Coder Resources
Merck Manual
CMS website for Prospective Payment Systems
TopOfPage
Coding Clinic
Medical dictionary
Anatomy & Physiology Book
Physician Desk Reference

4. Where do I begin? Read the entire record Face Sheet
History & Physical Exam
Progress Notes
Doctors Orders
Lab Results
Operative Notes
ER Notes, if applicable
Discharge Summary
Take notes
Write all diagnoses
Write all procedures

5. UHDDS
Inpatient data is collected based on the requirements of the Uniform Hospital Discharge Data Set (UHDDS)
Med Record/Control/Encounter number
Date of Birth
Gender
Race
Ethnicity
Residence
Hospital Identification
Admission and discharge dates
Physician identification
Discharge Disposition
Payer
All of the data collected is used to generate the UB-04 Claim Form 5

6. UB – 04 Form 6

7. FL67 Diagnosis Codes Source of the information
Field 67 is for the principal diagnosis. Fields 67a-q are for subsequent diagnoses
Each diagnosis field has 8 positions. The 8th position is for the POA (Present on Admission) indicator
Source of the information
These diagnosis codes should be assigned after review of medical record documentation and in accordance with official coding guidelines and entered by the HIM department 7

8. Admitting Diagnosis
Describes patient’s diagnosis at the time of admission
Required on all inpatient claims
Most often a symptom
One admitting diagnosis is reported

9. Admitting Diagnosis vs. Principal Diagnosis Examples
Admit: Gastrointestinal bleeding – 578.9
Principal: Acute duodenal ulcer with hemorrhage –
Admit: Acute cholecystitis – 575.0
Principal: Acute cholecystitis with cholelithiasis –
Admitting diagnoses can be symptoms as well as definitive diagnoses

10. Principal Diagnosis (PDX)
The condition established after study to be chiefly responsible for admission of the patient to the hospital.
Dependent on the circumstances of the admission
Dependent on coding directives in ICD-9-CM
Dependent on official coding guidelines 10

11. Additional Diagnosis Clinical evaluation Therapeutic treatment
Conditions that coexist at the time of admission or develop subsequently or affect patient care for the current hospital episode
Affect patient care defined as:
Clinical evaluation
Therapeutic treatment
Further evaluation
Extends LOS
Increase nursing care and/or other monitoring 11

12. Additional Diagnosis
Previous conditions – Code diagnoses that are on the final diagnostic statement like the discharge summary or the face sheet. History codes may be used a secondary codes if the condition or family history has an impact on current care or influences treatment.
Abnormal findings – Not reported unless the provider indicates their clinical significance. If findings are outside of normal range and the provider has ordered additional tests to evaluate the condition, querying the provider is appropriate.
Uncertain diagnosis – Probable, suspected, likely, questionable, still ruled out, or similar terms indicating uncertainty, code the condition as id it existed or was established. This bases for this guideline are the diagnostic workup, arrangements for further workup or observation. This only applies to inpatient coding only for short-term, acute, long-term care and psych hospitals.

13. Present on Admission Status Indicators
POA indicator is assigned to principal and secondary diagnoses
Present on Admission Reporting Guidelines can be found in the ICD-9-CM Coding Guidelines (pg. 95)
Status Indicators
Y = present at the time of inpatient admission
N = not present at the time of inpatient admission
U = documentation is insufficient to determine if condition is present on admission
W = provider is unable to clinically determine whether condition was present on admission or not
Definition: Present as the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.
Assigned to principal and secondary diagnoses and the external cause of injury codes.
Reporting Guidelines are housed in Appendix I.

14. Assign the POA Question #1
The physician documents in the patient history that the patient is admitted for acute and chronic bronchitis. The condition is coded to and What are the POA indicators for the acute and chronic bronchitis?
POA indicator: “Y” for both the acute and chronic bronchitis

15. Assign the POA Question #2
A patient with a severe cough and difficulty breathing is admitted from a private physician’s office. Following hospital work-up, a malignant neoplasm of the patient’s lung is diagnosed. What is the POA indicator assignment for the malignant neoplasm of the lung?
POA indicator: “Y” for the malignant neoplasm of the lung

16. Assign the POA Question #3
A patient is admitted for treatment of a lacerated spleen as a result of an automobile accident. Documentation also indicates that the patient has sickle cell disease. Two days following admission, a diagnosis of sickle cell crisis is made and the patient is treated. This condition is coded to What is the POA indicator for the sickle cell disease with crisis?
POA indicator:”N” for the sickle-cell disease with crisis as not all parts of the combination code were not POA

17. Assign the POA Question #4
A patient is admitted with a diagnosis of cough and fever, with a subsequent diagnosis of aspiration pneumonia. The physician has documented in the patient history and discharge summary that the patient has suffered a previous CVA with residual dysphagia. The dysphagia is reported with code What is the POA indicator for the dysphagia?
POA indicator: “blank” for the CVA with residual dysphasia as this code is on the codes and categories exempt list because these diagnoses do not represent a current disease or injury or are always POA. For purposes of CMS electronic processing , a “1” will need to be submitted for billing purposes.

18. Assign the POA Question #5
A patient is admitted into day surgery unit for elective repair of an inguinal hernia. Following the procedure, the patient develops acute exacerbation of COPD. The patient is subsequently converted to inpatient status. The code for the acute exacerbation of COPD is What is the POA indicator for the COPD?
POA indicator: “Y” for the acute exacerbation of COPD

19. FL74 Principal Procedure Code and Date
Source of the information
These diagnosis codes should be determine and entered by the HIM department
This is the ICD-9-CM code that identifies the principal IP procedure performed at the claim level
FL74a-e are for all significant procedures performed in addition to the principal procedure 19

20. Principal Procedure
Performed for definitive treatment (rather than diagnostic or exploratory purposes) or one that is necessary to care for a complication
If two or more procedures appear to meet the definition, the one more related to the principal diagnosis is designated as the principal procedure
If both are related, the one most resource intensive or complex 20

21. Significant Procedure
Surgical in nature
Anesthetic risk
Procedural risk
Specialized training
Infusions, catheterizations, and surgeries are examples of significant procedures. Surgical in nature: Surgery includes incision, excision, amputation, introduction, endoscopy repair, destruction, suture and manipulation.
Surgical risk would be manual rupture of joint adhesions (93.26)
Anesthetic risk: Any procedure that either requires or is regularly performed under general anesthesia carries anesthetic risk, as do procedures under local, regional, or other forms of anesthesia that induce sufficient functional impairment necessitating special precautions to protect the patient from harm.
Anesthetic risk would be eye examination under anesthesia (95.04)
Procedural risk: This term refers to a professionally recognized risk that a given procedure may induce some functional impairment, injury, morbidity, or even death. This risk may arise from direct trauma, physiologic disturbances, interference with natural defense mechanisms, or exposure of the body to infection or other harmful agents.
Procedural risk would be insertion of endotracheal tube that can tear the tissues (96.04) or blood transfusion (99.ox series) that can introduce harmful bacterial.
Specialized training: Any procedure that requires specialized training are those that are performed by specialized professionals, qualified technicians or clinical teams specifically trained to perform certain procedures. This is training above and beyond the education that is received by physicians, nurses or technicians.

22. Procedures not coded by HIM
Do not code procedures that fall within the code range through 99.99
Exceptions:
Cholangiograms
87.84 and Retrogrades, urinary systems
Arteriography and angiography
Radiation therapy
Psychiatric therapy
Alcohol/drug detoxification and rehabilitation

23. Procedures not coded by HIM
96.04 Insertion of endotracheal tube
96.70 – Mechanical ventilation
98.51 – ESWL
99.25 Chemotherapy

24. Hospital Chargemaster
A hospital chargemaster, also known as a chargemaster or CDM, contains the prices of all services, goods, and procedures for which a separate charge exists. It is used to generate a patient’s bill.
Services (procedure codes) that are captured by the chargemaster, are not coded by the inpatient coder.

25. Discharge Status Also known Status on the UB-04
Indicates where the patient went after discharge from the hospital
If long term care, psych, home health, rehab, cancer hospital, children’s hospital and SNF may impact payment to hospital for transfer MS-DRGs
Transfer to short term acute care impact payment regardless of MS-DRG 25

26. FL17-Discharge Status
This form identifies the discharge status of the patient related to the dates of services covered by the claim
Some options are:
01-D/C home
07-Left AMA
30-Still patient
Source of the information
The discharge status should be documented in the nursing notes and entered by HIM 26

27. Assigning DRG’s Age of the patient Sex Discharge Status
Diagnosis Codes with POA Indicator
Principal Diagnosis
Secondary Diagnosis (MCCs or CCs)
Procedure Codes
Principal Procedure
Significant Procedures
Presence or absence of a MCC or CC changes the rate of the DRG; For example if the PDX is , secondary dx, ; no change in DRG of 0303 = $ , DRG Weight = but when adding 486, the DRG is 0302 and the reimbursement rate is $5, and the DRG Weight =

28. MS-DRG Optimization
Optimization is the process of striving to obtain optimal reimbursement or the highest possible payment to which the facility is legally entitled on the basis of coded data supported by documentation in the health record. Not all MS-DRGs are affected by the presence of a secondary diagnosis. It can be determined by the MS-DRG title whether the MS-DRG is affected by the absence or presence of a CC or MCC. Example:
MS-DRG 193, Simple pneumonia and pleurisy with MCC,
MS-DRG 194, Simple pneumonia and pleurisy with CC,
MS-DRG 195, Simple pneumonia and pleurisy without MCC/CC,

29. MS-DRG Optimization
In the previous example, one way to optimize MS-DRG 195 would be to review the record further for documentation of a secondary diagnosis that would qualify for a CC or MCC. Other ways to optimize in the above case would be to review the record for the following:
An organism that is responsible for the pneumonia
Respiratory neoplasm
Septicemia
Mechanical ventilation
Opportunistic lung infection in a patient with HIV
Tracheostomy with mechanical ventilation over 96 hours
 Remember to optimize, supporting documentation must be included in the health record, and the definition for principal diagnosis must be met.

30. Physician Query Process
Query provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g., present on admission indicator).

31. Query Example
63 y/o patient was admitted with weakness, lung cancer, and not eating. The physical exam indicates dry skin with poor turgor. Lab revealed and elevated BUN and other electrolyte abnormalities. Physician order IV therapy and Medication Administration Record documents IV fluids at 100 cc/hr for two days.
Consider:
Is a query (ies) necessary?
What clinical indicators would you list on the query form?
How would you word the query to the physician?
Coding Clinic states that the principal diagnosis is that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. The physician did not state the principal diagnosis for this patient.
In this case, the patient was admitted with symptoms of weakness, failure to eat, in the presence of cancer. If that is the case, then the cancer may be principal, but the patient was treated only with IV fluids. The coder must query to determine the condition that chiefly caused the admission.

32. The End
Questions