REVENEWS ARCHIVE
RAC Update: Incorrect Coding
The RACs are keeping busy! In this article, we will review recent Inpatient hospital RAC findings related to incorrect coding.
Hospital Inpatient
Acute Respiratory Failure versus Respiratory Arrest
The RACs continue to identify coding errors when reviewing claims with the diagnosis of Acute Respiratory Failure.
Finding: As discussed in last month’s article, one of the latest findings that affected Inpatient Hospitals was the code assignment for the condition Acute Respiratory Failure. The problem discovered was Acute Respiratory Failure code 518.81 was sometimes being assigned when there was no physician documentation of Acute Respiratory Failure. Let’s look at another example relating to this error. During a PTCA, the patient became hypotensive, bradycardiac, was intubated and expired. The operative report has a documented diagnosis of respiratory arrest. No diagnoses are listed on the expiration summary. In this case, the provider coded Acute Respiratory Failure. After review of the medical record, the RAC determined there was no physician documentation of Acute Respiratory Failure. The Acute Respiratory Failure code 518.81 was deleted and the code for Respiratory Arrest 799.1 was added to the claim, based on documentation.
Lessons Learned:
- Understand and apply the definition of principal diagnosis at all times when coding inpatient claims
- Documentation of Acute Respiratory Failure must be present by the physician in order for Acute Respiratory Failure to be coded
- Coders cannot interpret clinical data and assign a diagnosis code for Acute Respiratory Failure without physician documentation stating this condition
- Have Coding Clinic guidelines available for reference
- Query the physician when clinical validation is required or if there is conflicting and/or ambiguous documentation present within the medical record
Acute Myocardial Infarction versus Coronary Artery Disease
The RACs continue to identify coding sequencing errors when reviewing claims with the diagnoses of Acute Myocardial Infarction and Coronary Artery Disease.
Finding: Coders were sometimes assigning Coronary Artery Disease as the principal diagnosis when documentation within the medical record supported Acute Myocardial Infarction as the principal diagnosis. For example, a patient was admitted through the Emergency Department with a pressure sensation in their chest. The Emergency Department physician documented Acute Myocardial Infarction. The patient underwent an emergency left heart catheterization and angioplasty was performed. During the procedure, the patient expired. The operative report listed the following diagnoses: “Left Heart Cath preoperative diagnosis of Acute Myocardial Infarction, showed severe CAD, angioplasty report preoperative diagnosis of Acute Myocardial Infarction”. A discharge summary was not present. The provider coded the Coronary Artery Disease as the principal diagnosis. After review of the medical record, Coding Clinic, 2nd Quarter 2001, and the definition of principal diagnosis, the RACS determined the Acute Myocardial Infarction should have been sequenced as the principal diagnosis with Coronary Artery Disease as a secondary diagnosis.
Lessons Learned:
- Understand and apply the definition of principal diagnosis at all times when coding inpatient claims
- Have Coding Clinic guidelines available for reference
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