DRGsDRGsImpact on ReimbursementImpact on Reimbursement

Medical Information Management Medical Information Management DepartmentDepartment

3 Key Rules for3 Key Rules forInpatient DocumentationInpatient Documentation

Probable, possible, or suspected conditionsProbable, possible, or suspected conditions SpecificitySpecificity Complications and Comorbid ConditionsComplications and Comorbid Conditions

Probable, Possible, or Suspected Probable, Possible, or Suspected ConditionsConditions

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

Chest PainChest Pain

Was it cardiac, GI, or musculoskeletal in Was it cardiac, GI, or musculoskeletal in origin?origin?

If cardiac, was it angina? Did a cardiac If cardiac, was it angina? Did a cardiac catheterization show disease? Document catheterization show disease? Document coronary artery disease if applicable.coronary artery disease if applicable.

Reimbursement ImpactReimbursement Impact

The following slide is intended to The following slide is intended to show the relationship between show the relationship between

various ways cardiac symptoms could various ways cardiac symptoms could be coded.be coded.

Reimbursement ImpactReimbursement Impact

Chest PainChest Pain $1$1

Angina PectorisAngina Pectoris $2$2

GI relatedGI related $3$3

GI related with comorbid GI related with comorbid conditioncondition

$4$4

SyncopeSyncope

Was the patient treated as if they suffered a Was the patient treated as if they suffered a TIA or CVA?TIA or CVA?

Was the event due to an embolus, thrombus, Was the event due to an embolus, thrombus, or carotid artery stenosis?or carotid artery stenosis?

Reimbursement ImpactReimbursement Impact

The following slide is intended to The following slide is intended to show the relationship between show the relationship between various ways syncope could be various ways syncope could be

coded.coded.

Reimbursement ImpactReimbursement Impact

SyncopeSyncope $1$1

TIATIA $2$2

CVACVA $3$3

SpecificitySpecificity

A coder may never assign a code on the basis of A coder may never assign a code on the basis of an abnormal finding alone.an abnormal finding alone.

The physician must ensure that the documentation The physician must ensure that the documentation provided is clear and concise.provided is clear and concise.

UHDDS Principal Diagnosis Definition – “That UHDDS Principal Diagnosis Definition – “That condition established after study to be chiefly condition established after study to be chiefly responsible for occasioning the admission of the responsible for occasioning the admission of the patient to the hospital for care.”patient to the hospital for care.”

Urosepsis vs. SepticemiaUrosepsis vs. Septicemia

The physician needs to specify if the The physician needs to specify if the diagnosis of urosepsis is intended to mean diagnosis of urosepsis is intended to mean 1) generalized sepsis (septicemia) caused by 1) generalized sepsis (septicemia) caused by leakage of urine or toxic urine by-products leakage of urine or toxic urine by-products into the general vascular circulation ORinto the general vascular circulation OR

2)urine contaminated by bacteria, bacterial 2)urine contaminated by bacteria, bacterial byproducts, or other toxic material but byproducts, or other toxic material but without other findings (UTI)without other findings (UTI)

Complication or ComorbidityComplication or Comorbidity

Conditions that affect patient care by requiring:Conditions that affect patient care by requiring: Clinical evaluation ORClinical evaluation OR Therapeutic treatment ORTherapeutic treatment OR Diagnostic procedures ORDiagnostic procedures OR Extended length of stay ORExtended length of stay OR Increased nursing care and/or monitoringIncreased nursing care and/or monitoring

A coder may never assign a code on the basis of an A coder may never assign a code on the basis of an abnormal finding alone.abnormal finding alone.

Rules of Medicare…Rules of Medicare… Just because it has a code, that doesn’t mean it’s Just because it has a code, that doesn’t mean it’s

coveredcovered Just because it’s covered, that doesn’t mean you can bill Just because it’s covered, that doesn’t mean you can bill

for itfor it Just because you can bill for it, that doesn’t mean you’ll Just because you can bill for it, that doesn’t mean you’ll

get paid for itget paid for it Just because you’ve been paid for it, that doesn’t mean Just because you’ve been paid for it, that doesn’t mean

you can keep the moneyyou can keep the money You’ll never know all the rulesYou’ll never know all the rules Not knowing the rules can land you in the slammerNot knowing the rules can land you in the slammer

Larry Oday – Attorney, Vinson & ElkinsLarry Oday – Attorney, Vinson & Elkins