Part 3: Most Common DRG’s with Recommendations – DRG 291

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 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.

#3: DRG 291—Heart failure and shock with MCC

DRG 291 (Heart failure with shock with MCC). This should be no surprise to coders that DRG 291 is in the top DRG’s with recommendation. It seems to always be in the top 5 and a focus for denials.

Records reviewed: 1738
DRG recommended changes: 104
Accuracy of DRG 291: 94.02%

I have no doubt that we will always see the DRG’s for congestive heart failure in the top 10 DRG’s.   HIA reviews many denial letters regarding congestive heart failure. These are typically for lack of clinical support of the condition or for clarification of the diagnosis.

Reasons for DRG 291 recommendations:

The majority of the recommendations from DRG 291 (Heart failure and shock with MCC) were due to addition, revision or re-sequencing of the PDX. Several of these did required a physician query to either support the PDX that was coded or to clarify a recommended PDX.

• 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 640 (Miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with MCC), 193 (Simple pneumonia and pleurisy with MCC), and 189 (Pulmonary edema and respiratory failure) and, 308 (Cardiac arrhythmia and conduction disorder with MCC).
• The second most recommended reason was for MCC validation or revision. A little less than half of these required physician query for clarification.
• There were just a couple of records that HIA recommended to add or revise a procedure code that did impact the DRG.

What can coders do to improve the accuracy of reporting DRG 291?

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.
• 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.