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In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits.
#5 DRG with the most recommendations during HIA reviews
DRG 853—Infectious & Parasitic diseases with O.R. procedure with MCC
The majority of the recommendations from DRG 853 (Infectious & parasitic disease with O.R. procedure with MCC) were due to revision, deletion or addition of PDX. The next most common reason for recommended changes for DRG 853 is due to revision or deletion of the ICD-10-PCS code that was reported. There were also a few records that the MCC was not able to be validated, so this was recommended to be deleted. Only 20% of the recommendations for this DRG required a physician query and changes were recommended based on documentation available in the medical record at the time of coding/review. DRG 853 was reported accurately only 84.78% of the time based on records reviewed by HIA in 2019 (552 records reviewed).
ICD-10-CM code A41.9 (sepsis, unspecified organism) was also the most common code that had a recommendation in 2019. The majority of these recommendations were revisions and/or deletions of the code and was reported at only 89.74% accuracy overall for 2019 HIA reviews.
What can coders do to improve accuracy of DRG 853?
- Review and verify that the diagnosis of sepsis is accurate at the time of final coding
- Verify the diagnosis of sepsis is clearly documented to be present on admission and didn’t develop after admission. If this is not clearly documented query may be necessary.
- Query when there is ambiguous documentation or there is any question to the validity of the diagnosis of sepsis
- Review the entire operative note when coding procedures
- Don’t rely on the title of the operative note to lead coders to the appropriate ICD-10-PCS code
- Look for the cause of sepsis—postoperative, post-traumatic, or is it due to a device
- Validate all MCC’s to ensure that documentation is in the medical record to support that these conditions should be reported. If there’s a chance that the condition may be ruled out, a query should be sent for clarification. When only 1 MCC is present on a record it is always best practice to double check to insure that the condition meets reporting requirements as well as clinical validity so that it is protected in any audits.
- If there is a question about a diagnosis in the record that does impact the DRG, a query should be sent or coders should follow the procedure for their facility to escalate the record to a senior reviewer or physician liaison
- Bottom line is to protect the DRG at final coding by making sure that it is correct, and there will be no question after final billing about the ICD-10-CM and 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 (Download our Sepsis eBook.)
Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P
References
ICD-10-CM Official Guidelines for Coding and Reporting FY 2020
ICD-10-PCS Official Guidelines for Coding and Reporting FY 2020
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.
