DRGs Impact on Reimbursement Medical Information Management Department

3 Key Rules for Inpatient Documentation Probable, possible, or suspected conditions Probable, possible, or suspected conditions Specificity Specificity Complications and Comorbid Conditions Complications and Comorbid Conditions

Probable, Possible, or Suspected Conditions When a diagnosis for an inpatient at the time of discharge is qualified as: “possible,” “probable,” “suspected,” “likely,” “questionable,” or “rule out,” the condition is coded as though the diagnosis were established. When a diagnosis for an inpatient at the time of discharge is qualified as: “possible,” “probable,” “suspected,” “likely,” “questionable,” or “rule out,” the condition is coded as though the diagnosis were established.

Chest Pain Was it cardiac, GI, or musculoskeletal in origin? If cardiac, was it angina? Did a cardiac catheterization show disease? Document coronary artery disease if applicable.

Reimbursement Impact The following slide is intended to show the relationship between various ways cardiac symptoms could be coded.

Reimbursement Impact Chest Pain $1 Angina Pectoris $2 GI related $3 GI related with comorbid condition $4

Syncope Was the patient treated as if they suffered a TIA or CVA? Was the patient treated as if they suffered a TIA or CVA? Was the event due to an embolus, thrombus, or carotid artery stenosis? Was the event due to an embolus, thrombus, or carotid artery stenosis?

Reimbursement Impact The following slide is intended to show the relationship between various ways syncope could be coded.

Reimbursement Impact Syncope$1 TIA$2 CVA$3

Specificity A coder may never assign a code on the basis of an abnormal finding alone. A coder may never assign a code on the basis of an abnormal finding alone. The physician must ensure that the documentation provided is clear and concise. The physician must ensure that the documentation provided is clear and concise. UHDDS Principal Diagnosis Definition – “That condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” UHDDS Principal Diagnosis Definition – “That condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

Urosepsis vs. Septicemia The physician needs to specify if the diagnosis of urosepsis is intended to mean 1) generalized sepsis (septicemia) caused by leakage of urine or toxic urine by-products into the general vascular circulation OR The physician needs to specify if the diagnosis of urosepsis is intended to mean 1) generalized sepsis (septicemia) caused by leakage of urine or toxic urine by-products into the general vascular circulation OR 2)urine contaminated by bacteria, bacterial byproducts, or other toxic material but without other findings (UTI)

Complication or Comorbidity Conditions that affect patient care by requiring: Clinical evaluation OR Clinical evaluation OR Therapeutic treatment OR Therapeutic treatment OR Diagnostic procedures OR Diagnostic procedures OR Extended length of stay OR Extended length of stay OR Increased nursing care and/or monitoring Increased nursing care and/or monitoring A coder may never assign a code on the basis of an abnormal finding alone.

Rules of Medicare… Just because it has a code, that doesn’t mean it’s covered Just because it has a code, that doesn’t mean it’s covered Just because it’s covered, that doesn’t mean you can bill for it Just because it’s covered, that doesn’t mean you can bill for it Just because you can bill for it, that doesn’t mean you’ll get paid for it Just because you can bill for it, that doesn’t mean you’ll get paid for it Just because you’ve been paid for it, that doesn’t mean you can keep the money Just because you’ve been paid for it, that doesn’t mean you can keep the money You’ll never know all the rules You’ll never know all the rules Not knowing the rules can land you in the slammer Not knowing the rules can land you in the slammer Larry Oday – Attorney, Vinson & Elkins