To Appeal or Not to Appeal? Carol Kerr, RHIA, CCS OrHIMA Fall Institute, 2014 The Art of Responding to External Coding Audits

To Appeal or Not to Appeal?

Carol Kerr, RHIA, CCSOrHIMA Fall Institute, 2014

The Art of Responding to External Coding

Audits

Audit “Truths”• They are going to happen.• The auditor is not always right.• There are resources to help:– AHA Coding Clinic– ICD-9 Official Guidelines– Briefings of Coding Compliance Strategies, HCPro– Getting It Right Upfront: Inpatient Documentation

and Coding, RACmonitor, MedLearn publishing.

• A well-written response letter can be very persuasive.

Coding “Truths”

Types of Coding Denials•Principal Diagnosis

Validation• Secondary Diagnosis

Validation

•Procedure Validation

Coding Scenario 1• 67-year-old patient presents with SOB, diagnosed

as acute diastolic heart failure – principal diagnosis. Audit finds that secondary code of 750.3 should not be coded, resulting in lower reimbursement.

• Past medical history lists “Schatzki’s Ring” – not specified as acquired so code 750.3, Esophageal Fistula, Esophageal Atresia and Stenosis, Congenital, is reported as a secondary diagnosis, which is an MCC.

• Appeal or not to appeal?• Lessons to be learned?

Coding Scenario 2• Patient admitted with SOB; imaging shows

CHF with mild pulmonary edema and trace pleural effusions. Code 428.0 is coded as principal diagnosis.

• Audit findings state that due to above documentation code 511.9, pleural effusion, should be reported, changing the DRG for increased reimbursement as 511.9 is a CC.

• Appeal or not to appeal?• Lessons to be learned?

Coding Scenario 3• Patient presented with abdominal pain with

associated nausea and vomiting and diagnosed with mesenteric ischemia; patient also has AKI, anion gap metabolic acidosis, and diabetes, not well controlled. Audit finds that code 250.12, diabetic ketoacidosis (which is an MCC), is not supported by the documentation and should be changed to 250.02, resulting in a decrease in reimbursement.

• Appeal or not to appeal?• Lessons learned?

Coding Scenario 4• Patient admitted with acute diverticulitis with

diverticular abscess per the H&P; post-op findings were diverticular abscesses x 2, sigmoid and descending colon, with contained abscesses in the mesentery; the op report states, “The patient's descending colon from its mid portion down to the rectosigmoid junction were essentially bound very tightly to the retroperitoneum. Beneath this retroperitoneum were 2 abscess cavities denoted by preoperative CAT scan. This mobilization was very careful along the line of Toldt and the ureter was visualized and protected throughout the case. The mesentery supporting the segment of bowel where the abscesses were was ligated and divided using 0 Vicryl sutures.”

Coding Scenario 4, cont’d• Audit findings were to revise 567.22 (an MCC),

peritoneal abscess, to 569.5 (a CC), abscess of intestine, stating, “While we agree the resident progress note documents an intra-abdominal abscess this abscess is further specified as a diverticular abscess in the additional progress notes, operative report and discharge summary. Please refer to the ICD-9 alphabetic index for Abscess, Intestine that leads to code 569.5.”


Coding Scenario 5• Patient admitted for partial revision of knee

replacement (tibia component); audit finds that 285.1, acute blood loss anemia, and 345.80, other forms of epilepsy (both CCs) should not be coded. Anemia is documented in postop progress notes; remote history of seizures documented on anesthesia record and patient is on Klonopin.


Coding Scenario 6• Patient admitted with an acute DVT and

documentation of CKD Stage IV, 585.4 (a CC); audit finds that clinical indicators do not support a diagnosis of CKD Stage IV, but CKD Stage III, so code should be changed to 585.3 for a decrease in reimbursement.


Coding Scenario 7• Patient presented with SOB, diagnosed with pneumonia in

the ER and admitted. The H&P states, “I think that this is acute CHF, not pneumonia but Pro BNP is pending and we are noting the response to IV lasix. I am not impressed that the CXR is any different than the last one 3-2013 which was when had had and EXACERBATION OF CHF ALSO.” The discharge diagnosis is systolic CHF, acute on chronic and documents, “He was given ceftriaxone and azithromycin by the ED, but after 40 mg lasix once, he diuresed almost 2 liters and felt much better with O2 sat over 90 on RA, This in combination with his proBNP of 2129 and a CXR looking just like the one from March 2013 when he had CHF convinced me that the main problem is acute decompensation of his CHF. I decided not to continue the antibiotics.” Audit finds that 486, pneumonia, should not have been coded as a secondary diagnosis.


Coding Scenario 8• Patient admitted for GIB and found to have an

angiodysplasia of the intestine with hemorrhage; H&P documents an atrial septal defect and refers to a “cardiac shunt” and “secundum ASD” on TEE earlier in the year; ASD also documented on anesthesia record and ASA score is 4. Audit finds that code 745.5, for the ASD, should not be coded stating “per the HP the patient has had previous cardiac shunt surgery for the ASD and therefore this diagnosis would not be collected as a secondary diagnosis.”

Coding Scenario 8, cont’d• Patient has documentation of a CABG and

pacemaker implantation in current chart; the echo referred to in the chart states, “2D echo and color Doppler findings are consistent with a secundum atrial septal defect with bidirectional shunting, although predominately left to right. The superior-inferior dimension of the ASD was 0.4 cm. There was a right-to-left shunt at rest by contrast study with agitated saline.”


Coding Scenario 9• Patient admitted with neutropenic fever

(288.04); also has AML and pancytopenia (patient has had chemo). Audit finds that reported code, 284.69 (an MCC), aplastic anemia is not supported by documentation, as the pancytopenia is documented as “transfusion dependent,” so code should be 284.19 (a CC).


Coding Scenario 10• Patient admitted with chest pain (determined

through a coding query to be a continuation of a previous NSTEM so coded with 410.72). Also coded, based on a coding query, was 428.41, acute combined systolic & diastolic heart failure (an MCC). Audit finds that 428.41 should not be coded as there are no clinical findings to support this diagnosis. There was a coding query asking for specificity for the heart failure (query gave choices) that was documented in the H&P, but in no other place.


Coding Scenario 11• Patient presented to ER with AMS, found to be most likely

due to hypoglycemia and hepatic encephalopathy . . . “no obvious acute precipitant although liver cancer can exacerbate encephalopathy . . . I think the reason we cannot get her ammonia level down is that the tumor is growing and there is not much liver left.” Treatment for ammonia level (lactulose); work up for the extent of the malignancy was addressed with a chest x-ray, abdominal ultrasound and a cranial CT, along with multiple discussions between the attending physicians, radiologists and outside physicians on how to treat the patient’s likely liver cancer. Audit finds that the principal diagnosis should be the hepatic encephalopathy and not the liver cancer with a decrease in reimbursement.


Coding Scenario 12• MS-DRG 455 was billed with principal

procedure code 81.08 (lumbar fusion, posterior technique), along with secondary code 81.06 (lumbar fusion, anterior technique). Audit finds that documentation does not support assignment of code 81.06. Op report documents, “360 fusion L4-4 with decompression L2-S1.” Only a posterior incision was made.

• To appeal or not to appeal?• Lessons learned?

Coding Scenario 13• Patient is admitted for an ileostomy takedown;

the op report states, “The bowel was divided on either side of the ostomy . . . then a running Vicryl was used around to approximate the small intestine.” Path report stated the small intestine segment measured 5 cm in length and 2.5 cm in diameter.” Audit finds that procedure code 45.62, partial resection of small intestine should not be reported, per AHA Coding Clinic 1991 2Q, which states minor trimming is included in the ileostomy takedown code, 46.51.


Coding Scenario 14• Patient presented with choledocholithiasis

with acute pancreatitis, based on CT evidence and labs; patient underwent ERCP with biliary stone removal and biliary dilation; discharge diagnosis is “gallstone pancreatitis”; choledocholithiasis is reported as the principal diagnosis. Audit finds that the appropriate principal diagnosis should be the acute pancreatitis, 577.0, citing the definition of principal diagnosis.


Coding Scenario 15• Patient admitted for a chief complaint of SOB and

worsening CKD; discharge summary states, “Patient with history renal transplant with known failure due to rejection with increasing fluid overload and shortness of breath despite OP attempts at diuresis. Admitted for evaluation and started on HD.” Original principal diagnosis was 403.91. Audit finds that the principal diagnosis should be V56.0, admission for renal dialysis.


Coding Scenario 16• The hospital reported a principal diagnosis code

assignment of 404.91, HTN heart and CKD with heart failure and CKD stage 3 and a secondary diagnosis code assignment of 486, pneumonia. The H&P documented “likely” cardiorenal syndrome (404.91) and leukocytosis “likely due to prednisone. Cannot exclude pneumonia.” Audit finds that the principal diagnosis should be 428.33, acute and chronic diastolic heart failure, and 486 should be removed, per the documentation that included no discharge summary or final progress note.

Coding Scenario 16, cont’d• Documentation review showed that the

discharge summary and final progress note were available at final coding; no documentation of cardiorenal syndrome, but discharge diagnosis of acute on chronic diastolic CHF. Patient does have HTN and CKD 3; listed as a discharge diagnosis is “leukocytosis with productive cough and asymmetrical CSR, treated empirically for possible pneumonia.”


Coding Scenario 17 • The hospital assigned a principal diagnosis of 996.69,

infection due to device NEC, and secondary diagnosis code assignment of 998.33, disruption of traumatic wound injury. Documentation specified an admission due to wound dehiscence and infection due to the patient taking sutures out. Audit replaced principal diagnosis of 873.1, open wound of scalp with complication and removed code 998.33.

• Documentation shows that the patient did pull his sutures out, but the sutures were from a surgery one week prior to this admission where a cranioplasty with implant was done. For this admission the surgeon documented that removing the sutures and opening the scalp exposed the implant, which is now infected and must be explanted.


Coding Scenario 18• Patient admitted with UTI, has a chronic Foley

catheter due to neurogenic bladder; also has hemiplegia due to CVA; developed acute systolic CHF during admission. Audit finds that there is no clear documentation of the causal relationship between the UTI and the catheter, so principal diagnosis code 996.64 was removed and replaced with 599.0 per AHA Coding Clinic 2012 2Q.


Coding Scenario 19• Patient complains of dyspnea, back pain,

dysuria and fever of 2 days duration; found to have COPD exacerbation and a UTI; blood cultures grew E. coli. Discharge diagnoses are septicemia due to E. coli, COPD exacerbation and UTI with 491.21 (COPD exac.) assigned as the principal diagnosis. Audit finds that the septicemia should be the principal diagnosis with UTI/COPD secondary as per the Official Coding Guidelines Chapter 1.


Coding Scenario 20• Patient admitted with renal and perinephric

abscess (also has ESRD and uncontrolled DM); the progress note on day 2 documents, “Sepsis 2/2 pyelonephritis 2/2 staghorn calculi with evidence of perinephric abscess on CT,” (this same physician was the discharging physician). Since the sepsis was not documented on the discharge summary the coder sent this coding query: “A localized infection of pyelonephritis is documented in the patient record. The medical record reflects ‘Sepsis 2/2 perinephric abscess.’ Is there also a systemic infection? The blood cultures were negative?”

Coding Scenario 20, cont’d• Physician’s answer: “I do believe that this gentleman

had sepsis which is Systemic inflammatory response syndrome + and infection when he fist presented. Initially he had tachycardia, tachypnea and fevers which qualifies as "SIRS". His infection was the perinephric abscess which required surgery to remove. He was also quite hypotensive. Over time his " SIRS" resolved but his infection persisted necessitating a transfer to OHSU for removal.”

• Audit finds that the principal diagnosis should be 590.2, renal and perinephric abscess, since the diagnosis of sepsis is not introduced into the record until five days after admit.


Thank you!Carol Kerr, RHIA, CCS

Coding SupervisorGood Samaritan Regional Medical

Center Corvallis, Oregon

[email protected]

Documents

To Appeal or Not to Appeal? Carol Kerr, RHIA, CCS OrHIMA Fall Institute, 2014 The Art of Responding to External Coding Audits