Part 4: Most Common DRG’s with Recommendations – DRG 189

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. 

#4: DRG 189—Pulmonary edema and respiratory failure

DRG 189 (Pulmonary edema and respiratory failure). This should be no surprise to coders that DRG 189 is in the top DRG’s with recommendation. It seems to always be in the top 5 and a focus for denials. 

Records reviewed: 665
DRG recommended changes: 104
Accuracy of DRG 193: 84.36%

Respiratory failure will most likely be one of the top reviews with recommendations forever. Or at least that is how it seems. HIA reviews many denial letters regarding respiratory failure. These are typically for lack of clinical support of the condition or for clarification of the diagnosis.  

Reasons for DRG 189 recommendations:

The majority of the recommendations from DRG 189 (Pulmonary edema and respiratory failure) were due to addition, revision or re-sequencing of the PDX. Only a few required a physician query to either support the PDX that was coded or to clarify a recommended PDX. When patients present with respiratory issues there is typically several issues going on at once. Respiratory failure is not in the symptom chapter within ICD-10-CM, but it is always caused by something else.

• The most common reason for change is adding a new, re-sequencing, or obtaining clarification of the assigned PDX. Only a few of these did require physician query to clarify the medical record documentation. The DRG’s that were most commonly recommended were 177 (Respiratory infections and inflammations with MCC), 190 (Chronic obstructive Pulmonary disease with MCC), 193 (Simple pneumonia and pleurisy with MCC), 291 (Heart failure and shock with MCC), and 871 (Septicemia or severe sepsis without MV >96 hours with MCC). If you notice, all of the recommended DRG’s are also DRG’s that are common for coding errors as well as focused on during reviews.
• There were just a couple of records that HIA recommended to add or revise a procedure code that did impact the DRG. One was addition of the mechanical ventilation code and the other was a lung biopsy procedure. 

What can coders do to improve the accuracy of reporting DRG 189?

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.
• 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. An example that comes to mind, and that we see often, is a patient admitted with shortness of breath and diagnosed with acute respiratory failure and pneumonia on admission. The clinical indicators do not support that the patient is in acute respiratory failure with only 2 liters of O2 needed. O2 sats were never below 92 even without the addition of the oxygen. The pneumonia is treated with five days of IV antibiotics and on discharge to continue 10 days of p.o. antibiotics. The patient had multiple follow up chest x-rays during the hospitalization to look for improvement of the pneumonia due to ongoing fever. What is the coder to do? In this case, the coder should report pneumonia as the PDX and query the physician or contact CDI (depending on the facility policy) to clarify the diagnosis of acute respiratory failure and to ascertain what criteria the physician used for this diagnosis. Without a physician query and clarification, the diagnosis acute respiratory failure wouldn’t be reported as a PDX or a SDX. Based on the treatment, the pneumonia was more resource intense and required more treatment, which makes these conditions no longer coequal. Even for a SDX it would not be appropriate to report the acute respiratory failure without clarification. For each record that has more than one possible PDX, especially in the respiratory system, it is best to walk each case through the coders mind to weigh out the treatment.
• 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.

There is also a document on HIA’s blog discussing acute pulmonary edema if you’d like to read a little about this: https://www.hiacode.com/education/reporting-flash-pulmonary-edema/

References
ICD-10-CM Official Guidelines for Coding and Reporting FY 2022
ICD-10-PCS Official Guidelines for Coding and Reporting FY 2022
AHA Coding Clinic 4Q2017, Page 96
AHA Coding Clinic 1Q2017, Page 24
AHA Coding Clinic 3Q2016, Page 15

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.