This is the next most common DRG with recommendations found in HIA reviews in 2021. Just to recap, HIA reviewed almost 50,000 inpatient records and over half a million codes in 2021. We will look at the top DRG’s with recommendations and see what can be done to prevent DRG changes going forward. Each coding tidbit will contain some tips for coding within the DRG or diagnosis area.
#2: DRG 177/178—Respiratory infections and inflammations with MCC/CC
DRG 177 (Respiratory infections and inflammations with MCC) and 178 (Respiratory infections and inflammations with CC). This should be no surprise to coders that DRG 177 is in the top DRG’s with recommendation. It seems to always be in the top 5 and a focus for denials. I did combine these two DRG’s as the reasoning behind the recommendations were almost identical.
Records reviewed: 4133
DRG recommended changes: 202
Accuracy of DRG 291: 87.30%
I have no doubt that we will always see the DRG’s for infections and inflammations with MCC in the top 10 DRG’s. HIA reviews many denial letters regarding specified bacterial pneumonia, lung disorders, and aspiration pneumonia. Most of these are due to insufficient or conflicting documentation of the PDX or of the reported CC/MCC that was not clarified prior to final coding.
Reasons for DRG 177/178 recommendations:
The majority of the recommendations from DRG 177/178 (Respiratory infections and inflammations with CC/MCC) were due to addition, revision, or re-sequencing of the PDX. Most of these did not require a physician query to clarify since the documentation was present in the documentation at the time of coding.
- The most common reason for change is adding a new, re-sequencing, or obtaining clarification of the assigned PDX. Several of these did require physician query to clarify the medical record documentation. The DRG’s that were most commonly recommended were 871 (Septicemia or severe sepsis without mechanical ventilation >96 hours with MCC), 189 (Pulmonary edema and respiratory failure), 193 (Simple pneumonia and pleurisy with MCC), and 291 (Heart failure and shock with MCC). The majority of these did not require a physician query to support the recommended change.
- The second most common reason for change in this DRG pair was addition, deletion, or revision of the CC/MCC that was reported. Less than half of these required physician clarification.
- Another recommendation that was common was due to the addition of the PCS codes for mechanical ventilation. Ventilator flow sheets and respiratory records should always be reviewed when coding. These are very significant in reimbursement and avoidable. None of these required a physician query for clarification.
- There were also several records that were reviewed that stayed in the same DRG but had financial change due to the addition, deletion, or revision of the COVID-19 ICD-10-CM code. It is imperative to keep up with the latest and greatest COVID-19 reporting guidelines while we withstand the pandemic.
What can coders do to improve the accuracy of reporting DRG 177/178?
The most important thing that a coder can do is to make sure that there are no questions that could be raised regarding any diagnosis or procedure that is used to calculate the DRG. Ask yourself these questions when coding:
- Verify that the assigned PDX has no room for questioning. If there is any documentation that contradicts or is unclear, the physician should be sent a query to clarify.
- Double check respiratory records for mechanical ventilation and respiratory flow sheets.
- Validate all CC/MCC’s assigned and if a query is needed to clarify or support these, it should be sent at the time of original coding.
- Remember the official coding guideline that tells us that in the rare occasion when two or more diagnoses equally meet the criteria for PDX, either may be sequenced first. It is important to know the clinical picture of these patients so that coders can determine if treatment was equal or not.
- Query anytime there is ambiguous of conflicted documentation prior to coding finalization
- Bottom line is to protect the DRG at final coding by making sure that it is correct, and that there will be no question after final billing about the ICD-10-CM and/or ICD-10-PCS codes that were reported.
Coders should review the entire medical record to look for any conflicting documentation and clarify this prior to final coding. Clarification prior to final coding will decrease audit recommendations and denials. Remember, denials are costly to the facility with all the time that is spent trying to appeal.
References
ICD-10-CM Official Guidelines for Coding and Reporting FY 2022
ICD-10-PCS Official Guidelines for Coding and Reporting FY 2022
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.