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CUREMarch-April 2003This issue is available in Adobe Acrobat format.
Coder blows whistle on DRG upcoding over five years at Tennessee hospitalIn late January, Maury Regional Hospital in Columbia, TN, settled a $2 million whistleblower suit for alleged diagnosis-related group (DRG) upcoding over a five-year period, filed by Ed Taylor, a DRG coder at the facility. Maury denied any wrongdoing in the case. Taylor’s case alleged a host of DRG miscoding, including the following examples that have long been Office of Inspector General (OIG) fraud targets:
The lawsuit stated that coders were instructed to use complication modifiers to upcode based on anything written in the chart. “For instance, if alcohol was written anywhere in the chart and a CC was needed, coders were instructed to assume alcoholism or alcohol abuse,” according to the suit. “You don’t see that level of specificity every day in descriptions of cases,” says William Mahon, president and chief executive officer of the National Health Care Anti-Fraud Association. The allegation that the supervisors were specifically instructing the coders how to upcode is somewhat unusual, he adds. “One way or another, in these DRG upcoding cases, someone is making a decision that something is going to be upcoded. The question is how specific is the instruction.” Mahon admits that there is often legitimate debate over what constitutes correct coding. “There can be questions because there is significant turnover of CPT codes every year,” he says. “There are also misunderstandings of what one Medicare carrier will cover v. another— there are regional variations in Medicare benefits and coverage. “There can be legitimate misunderstandings about what was done based on the physician’s documentation.” However, a hospital’s compliance program and auditing process should catch that unintentional miscoding. “Hospitals should be auditing themselves before somebody else comes along and does it for them,” Mahon says. “Insurers routinely audit hospital billings separate and apart from any anti-fraud operation, and most problems that come up are dealt with that way.” Do you need to worry about whistle- blowers at your facility? Not necessarily, says Mahon. The OIG contacts the hospitals involved in fraud cases numerous times before it brings charges, he says. “When something gets to the point of a fraud investigation, it generally means that somebody knowingly did something they shouldn’t have done.” According to Ken Nolan, Taylor’s attorney, whistle- blower cases generally have one thing in common—the relater’s “complaints fall on deaf ears and they’re told to do it or get another job. That’s almost always the case.” To avoid a case similar to that of Maury Regional’s, Mahon recommends you make sure your facility has the following:
But these measures shouldn’t be viewed as a means of protecting your facility from whistleblowers. “If you’ve got a whistleblower it means you’ve got bigger problems than a whistleblower,” Mahon says. Taylor plans to continue working as a coder, just as he continued coding throughout the case, Nolan says. Hospitals shouldn’t have a problem having a qui tam relater [whistleblower] in their midst, he adds. “Some employers recognize the fact that it shouldn’t matter if you have a former qui tam relater on staff if you’re not doing anything wrong.” Nolan says these types of fraud cases are likely to trickle off in the coming years for several reasons. “The [OIG’s] pneumonia project identified a lot of hospitals that may have been over- paid, so I think that as the years go by more and more hospitals have corporate compliance programs, they’re being more effective, and they have increased awareness of the False Claims Act.” “It is a fact that there are many more compliance programs than ever existed before,” Mahon adds. However, he sees a dichotomy among compliance programs. “Some are serious and others are window dressing. The ones whose compliance programs are window dressing are the ones that will have to learn a hard lesson before they get better.” Reprinted from Briefings on Coding Compliance Strategies. For more information, call (800)-650-6787 or e-mail HcPro Customer Service.
Principles of Coding:Mental DisordersEach issue of CURE will focus on the principles of ICD-9-CM or CPT coding for a particular disease or body system. In this issue we’ll review the coding of mental disorders within ICD-9-CM and will focus on the codes used to describe psychosis, schizophrenia and organic brain syndrome. Be sure and complete Test Your Knowledge with the abstract and questions provided to receive two (2) CE credits.This program has been approved for 2 continuing education credits for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). The Test Your Knowledge quiz and CE credits are available only to IRP customers and paid subscribers to CURE. PsychosisPrinciple: Psychosis, which can be attributed to a prescribed or non-prescribed drug, is classified to Drug Psychoses (292). An additional code should be used to designate any associated drug dependence (for example, 304.X). And, remember to apply the E code to identify any associated dependent drug or medication.
Principle: Drug withdrawal shall be coded to 292.0 (drug psychoses, drug withdrawal syndrome). Other psychoses associated with drug dependence/abuse are coded to 292.XX (drug psychoses). The psychosis shall be designated as the principal and the substance abuse or dependence as the secondary. An additional E code should be used to identify the drug type.
Metabolic EncephalopathyPrinciple: Metabolic encephalopathy (or acute confusional state) refers to many conditions (e.g., acute alcohol withdrawal, drug-induced delirium). Code metabolic encephalopathy and assign as the principal only if disorder’s cause is not determined.
Organic Brain SyndromePrinciple: In the coding of organic brain syndrome, the coder must first determine if the syndrome is of psychotic or non-psychotic nature. If psychotic, the associated condition must be documented and coded additionally. If documentation within the record does not conclusively state that a psychosis is present in conjunction with the organic brain syndrome, code to the non-psychotic category.
SchizophreniaPrinciple: Schizophrenia is classified to the 295 code category with the 5th digit indicating the course of illness. The specific course of illness must be documented by the physician; the coder should never assume a stage of illness. If unsure as to the definitions relative to course of illness, review the Glossary of Mental Disorders.
Adjustment and Acute/Chronic Stress ReactionPrinciple: The coder must determine the length and significance of adjustment and chronic stress reactions prior to code assignment. Adjustment reactions are generally considered mild or transient but lasting longer than acute stress reactions. If stress reactions last more than a few months, verify, (with physician) if a chronic condition exists.
Managing Successful Coding and Billing AuditsCoding and billing is one of many high-risk areas that continually challenge organizational leadership. One major reason this area is high risk is the myriad of complex and ever changing coding and billing rules and regulations that need to correctly interpreted and applied, and the amount of overpayments that can quickly accrue if the rules are not followed to the letter. Here are some key concepts to consider that help ensure successful auditing of coding and billing operations. Team makeupThe Internal Audit/Compliance Department should have overall responsibility for selecting audit team members who have the requisite expertise in the areas to be audited. It is especially important to involve Health Information Management and Patient Accounts leadership in as many phases of the audit as possible. One important function of the billing and coding staff is providing the auditors with the training necessary to conduct the audit. Communicating resultsOne effective means for obtaining the important buy-in to eventual audit findings and recommendations is to communicate with key management early and often in the audit process. Key management includes pertinent committees, senior management, the board of directors, and the leadership of the departments directly affected by any part of the audit. Follow-up and corrective actions: The audit does not end with the issuance of the audit report and communicating the results to the leadership. More often than not lip service is paid to corrective action recommended in the audit report. The test of buy-in is whether or not responsible parties actually correct the deficiencies noted in the audit and implements all of the recommended corrective actions timely and accurately. It is up to the auditors and or compliance staff to persist until it happens.
CLINICAL CODING EXPERTStep by Step: Expert Coding CheckAs HIM professionals, we want to be assured that we are providing the highest quality data for reimbursement and research purposes. Clinical Coding Expert helps us review each case as we code the chart. Expert Coding Check analyzes each case for clinical review against the CMS Medicare Provider and Review File (MedPAR), a database of nearly 40 million case abstracts compiled from the data submitted by hospitals for all inpatient Medicare discharges. Clinical Coding Expert identifies diagnoses or procedures that may be present in the chart but not yet coded, or that are not properly documented. The result is improved compliance and reimbursement. 
Figure 1 shows the In-Patient Data Entry Screen of our initial coding for a 73-year-old male admitted for Angina (411.1). Clicking the Coding Check button takes us to the Expert Coding Check screen. Clinical Coding Expert prompts us to “Check for AMI or Cardiological Complication.” “Check for Major Secondary Diagnosis” or “Check for Major Procedure”. 
Each entry lists the statistical probability of the complication, the new DRG, its weight, and the potential change in reimbursement. In the Probability column of the first entry, we see “V Lo”; statistical analysis shows a very low percentage of 73 year-old males with angina also had an AMI or a Cardiological Complication. However, the weight for DRG 121 is 1.621, considerably higher than our initial 0.5382 for DRG 140. Clicking on the entry takes us to the Details screen, which tells us “Coding BOTH a CV Complication AND an AMI improves reimbursement,” and lists the most common of each, in order of probability. 
If we suspect the patient has an undocumented complication - for example, the patient’s record contains a prescription for digoxin which we know is used to treat atrial fib - we might query the doctor to provide clarification or more complete documentation of the Atrial Fibrillation. If the record supports it, the DRG would change to 121, and the reimbursement would improve 201%. With our additional documentation, we can add the code automatically by clicking the line for Atrial Fibrillation, which takes us back to the In-Patient Data Entry Screen, where we see 427.31 added below 411.1. 
Expert Coding Check is just one of many examples how Clinical Coding Expert helps to code easily and correctly.
Shared Vision – New PathwaysFor years JCAHO has been criticized for not being sensitive to the needs of its customers. It’s getting so bad that many healthcare organizations are choosing not be participate in the accreditation process. JCAHO has responded by creating a survey process modeled on continuous quality improvement (CQI). It’s been dubbed Shared Vision — New Pathways!! Critical elementsRather than once every three years surveys, beginning in 2004, JCAHO will be doing “continuous surveys.” Critical elements of the new accreditation process include a major consolidation of existing Joint Commission standards, the introduction of a self-assessment process, use of data from multiple sources (including the self- assessment) to guide the on-site accreditation survey, and conducting the on-site evaluation in the context of tracking actual individual experiences. Benefits of the new survey process include:
Enhanced surveyor focusChanges in the accreditation process, progressively being implemented and to be in place by January 1, 2004, will enhance the organizations and surveyors’ focus on critical care processes that are directly linked to safety and quality issues. The new approach includes:
Other initiativesThe Joint Commission has already initiated a number of other enhancements that are part of the future accreditation process. These include an electronic Request for Survey, formal certification for surveyors, and a consolidated database of standards for all of the Joint Commission’s accreditation programs. An integrated survey process for complex organizations (to replace the current “tailored” survey process), announced earlier this year, will create further accreditation process efficiencies. Shriners Hospitals for Children, in Spokane, says on the web site that self-assessment is an integral part of JCAHO’s new accreditation process for 2004, dubbed Shared Visions — New Pathways. The self-assessment process aims to support continuous standards compliance and free up surveyor time during the on-site survey to concentrate on the organizations critical focus areas and provide practical, educational support. More about Shared Visions can be found at www.jcaho.org.
Incorrectly billing for same-day, same- provider readmissions gets OIG’s attentionLearn from a recently issued Office of Inspector General (OIG) report chiding hospitals in Pennsylvania to bill correctly for same-day same provider readmissions. The OIG found that several Pennsylvania hospitals received about $290,000 in incorrect payments due to hospital admission that were billed incorrectly. The OIG reported that 63 of 98 same-day, same-provider readmissions that were analyzed were billed incorrectly. The billing errors were the result of the patient being either admitted to a nonacute care unit within the hospital or the patient was never discharged from the initial admission. To fix the problem, the OIG asked that the Philadelphia regional Centers for Medicare and Medicaid Services (CMS) office:
To read the report, go to http://oig.hhs.gov/oas/reports/region3/30100011.pdf. The report is titled “Review of Medicare Same-day, Same-provider Acute Care Readmissions in Pennsylvania During Calendar Year 1998 (A-03-01-00011). The OIG has reported on this problem in the past, and will continue to do so make it a point to monitor these claims.
CMS Explains E&M Billing for Non-physician PractitionersThe Centers for Medicare and Medicaid Services has issued an important explanation, Transmittal No.1776, about the rule on billing for evaluation and management services performed by non-physician practitioners (NPPs) and those shared between a physician and NPPs. Medicare will pay for E/M services for specific NPPs (i.e., nurse practitioner, certified nurse midwife, etc.) whose Medicare benefit permits them to bill the services. A physician’s assistant may also provide physician service. However, physician collaboration and general supervision and all billing rules apply to all NPPs. Independent PracticeMedicare will not pay for CPT E/M codes billed by physical therapists or occupational therapists in independent practice. Office/Clinic SettingWhen an E/M service is a shared encounter between a physician and a NPP, the service is considered to have been performed incident to if the appropriate requirements are met and the patient is an established patient. If incident-to requirements are not met for the shared E/M service, the service must be billed under the NPP’s provider number. For example, in an office setting an NPP performs a portion of an E/M encounter and the physician completes the E/M encounter. If the incident-to requirements are met, the physician bills the service. If the incident-to requirements are not met, the service must be billed using the NPP’s provider number. Shared VisitsWhen a hospital inpatient/hospital outpatient or ED E/M is shared between a physician and an NPP for the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician’s or NPP provider number. Medical NecessityThe Transmittal reminds us that the service must be medically necessary and be within the scope of practice for a NPP in the State in which the NPP practices.
OIG Observation AuditsThe U. S. Department of Health and Human Services (HHS), through the Office of the Inspector General (OIG), lists audits of various hospitals on their website. Observation services have been targeted in the past and will continue to be an area of concern to OIG. Although the OIG audits cover the period before implementation of OPPS, a review of this material may alert hospitals to errors they still could be making in current observation billing. Various hospitals reviewed in these audits did not meet Medicare requirements for observation services. The same problems existed in almost all of the OIG reviews. The most common problem was that a physician’s order for observation was not documented in the patient’s medical record. Medicare criteria state that observation services are permitted only when ordered by a physician or another individual authorized to admit patients to the hospital or to order outpatient tests. Charts with standing orders for observation prior to or following outpatient surgery were cited by OIG. These orders were not legal because Medicare believes that these were provided for the convenience of the patient, his or her family, or physician. To qualify, orders must be written for services which meet the medical necessity criteria. The audit cited specific language in the medical record — “no complications” or “patient tolerated the procedure well” to prove the inappropriateness of billing for observation following an outpatient procedure. This language indicates a routine outpatient procedure — not one eligible for additional Medicare reimbursement. Many of the ineligible claims had an incorrect number of observation hours recorded. In some cases a hospital billed as observation hours all the time a patient spent having a routine outpatient procedure — starting with the time the patient arrived at the hospital for the procedure, including the time the patient was in the procedure suite and recovery unit, and ending with the time the patient was discharged. In other cases the physician had clearly written an order to admit the patient into the hospital while the claim was submitted as an outpatient procedure. Obviously, the implementation of a separate APC for observation for services furnished on or after April 1, 2002 dictated new guidelines that hospitals must follow to be eligible for reimbursement for these services. Claims must meet the regulatory requirements for the time when the services were furnished — not for the time when the claim was submitted. A review of these audits shows the necessity for constant in-house monitoring of claims to ensure correct and timely reimbursement.
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