HIA reviewed almost 50,000 inpatient records and over half a million codes in 2021. I’m sure that coders could guess the DRG that had the most recommendations. There are some diagnoses and DRG’s that will always be a thorn in the side for coders. We will look at the top DRG’s with recommendations and see what can be done to prevent errors going forward. I’m sure everyone guessed or new it would be sepsis that was the #1 most common DRG with recommendations.
Reviewed DRG 871: 2690
DRG recommended changes: 232
Accuracy of DRG 871: 91.38%
#1: DRG 871—Septicemia or severe sepsis w/o mechanical ventilation >96 hours with MCC
Sepsis is and will most likely always be a troubled area for coders. There are multiple reasons for this and we will look at a few of these. There are many different criteria being used to validate the diagnosis of sepsis. Denials are usually due to a payer using a specific set of criteria to validate and the physician using another. Even though coders are to use the physician’s documentation to code from, coders also must make sure that the clinical picture of the patient is also consistent with the severe diagnosis of sepsis. However, the reasons for the DRG recommendations for sepsis in our reviews were not solely based on clinical criteria. Most were due to lack of or conflicting documentation within the record.
Reasons for Sepsis DRG recommendations:
- Principal diagnosis change. Well over ¾ of the recommendations were due to change in PDX. These changes were due to the incorrect PDX being selected. It was almost an even amount that required a query and those that did not. Oftentimes, the diagnosis would be ruled out in the body of the discharge summary or in another area in the record. Some of the changes were due to lack of clinical support for sepsis. In those cases a query was recommended to clarify the diagnosis of sepsis. Afterall, sepsis is a serious condition and it is likely not going to be fully treated in just a day or two. Most cases that required a query were due to the documentation not being clear within the record. If there’s any doubt that the condition existed or was present or not, a query is necessary. There should be no question of the diagnosis when the record is finalized.
- Missed procedure codes. These were either missed mechanical ventilation codes, inaccurate mechanical ventilation time reported, or another surgery that resulted in a surgical DRG. It is imperative that coders review the mechanical ventilation notes to get the exact times the patient was on the ventilator. Also, some recommendations were due to missed procedures such as debridements and I&D’s that were in the record.
- Addition/Deletion of MCC. Some of these recommendations were asking for specificity of a secondary diagnosis that resulted in addition and/or removal of an MCC. All MCC’s should be clear of needing queries at the time of coding finalization. When denials or audits are performed, these are errors since the clarification should be sought prior to completion of coding. It’s a good idea for coders to double check any code that is “driving” the DRG.
What can coders do to improve the accuracy of reporting DRG 871?
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 that is used to calculate the DRG. Ask yourself these questions when coding:
- Review and verify that the diagnosis of sepsis is accurate at the time of final coding
- Look for causes of sepsis and if there is a link to a device or other complication
- Is sepsis supported? Is a query necessary to clearly document the diagnosis?
- Is the diagnosis of sepsis dropped after admission without clearly ruling out the condition? Query when necessary.
- Is the diagnosis of sepsis documented after admission without clear documentation of the condition being present on admission?
- Are there any chapter specific guidelines that should be followed?
- Was the patient on mechanical ventilation? If so, double check the hours for appropriate reporting
- Does the discharge summary contradict or conflict with the rest of the medical record documentation? When this occurs, it is often necessary to query for clarification.
- Review the medical record for any and all procedures that were performed. If there is anything in the operative note that needs to be clarified that should be completed at the time of coding. Depth of debridement is a very common reason for change based on ICD-10-PCS codes as well as specificity in hours for mechanical ventilation.
- Review the medical record for any past or current conditions and complications. If the documentation is not clear, a query may be needed.
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 (see the 5 part Sepsis Series published November 2019). The E-Book on this series can be downloaded on our website here: https://www.hiacode.com/blog/resources/
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.