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RAC Findings

Before we get down to business with our last article of 2011, G2N would like to take this time to wish you and your family a safe and happy holiday season! We have been busy in 2011 sharing ICD-10-CM/PCS information and passing along RAC findings. As we move forward into 2012, we plan to continue sharing up to date information related to these topics. In this article, we will learn about another RAC finding that affects Inpatient Hospitals.

Validation of Medicare Severity Diagnosis Related Group (MS-DRGs) With Ventilator Support of 96 or More Hours

The RACs have discovered that providers are incorrectly adding the number of ventilator hours during Inpatient admissions or they are selecting incorrect procedure codes for the mechanical ventilation which is resulting in higher reimbursement. The ventilator weaning time should be included when adding hours for mechanical ventilation. It is incorrect for coders to look at the number of days a patient was in the facility to determine ventilation hours.

The RACs validated MS-DRGs 003, 004, 207, 870, 927 and 933. These DRGs include ventilator support of 96 or more hours. Claims for hospitalizations containing mechanical ventilation of less than 96 hours were identified with one of these reported DRGs.

Below are two examples:

Case A: A 52 year old patient was admitted through the emergency room on June 21, 2009. Upon admission at 4:44 A.M., the patient was placed on a ventilator. The patient expired at 3:45 A.M. on June 24, 2009. Intubation time was 71 hours. The provider reported procedure code 96.72 (Continuous Invasive Mechanical Ventilation for 96 Consecutive Hours or More). Medical record documentation shows the patient was on the mechanical ventilator for approximately 71 hours.

Procedure code 96.71 (Continuous Invasive Mechanical Ventilation for Less than 96 Consecutive Hours) should have been reported based on medical record documentation. Correct procedure code reporting would have changed the MS-DRG from 207 (Respiratory System Diagnosis with Ventilator Support 96 or More Hours) to MS-DRG 208 (Respiratory System Diagnosis with Ventilator Support Less Than 96 Hours).

Case B: An 84 year old patient was admitted through the emergency department on May 19, 2009. On May 20, 2009 the patient expired. The provider incorrectly reported procedure code 96.72 (Continuous Invasive Mechanical Ventilation for 96 Consecutive Hours or More). Medical record documentation shows the patient was on the mechanical ventilator for approximately 12 hours.

Procedure code 96.71 (Continuous Invasive Mechanical Ventilation for Less than 96 Consecutive Hours) should have been reported based on medical record documentation. Correct procedure code reporting would have changed the MS-DRG from 870 (Septicemia or Severe Sepsis with Mechanical Ventilation 96 or More Hours) to MS-DRG 871 (Septicemia or Severe Sepsis without Mechanical Ventilation 96 or More Hours with MCC).

Lessons Learned

Providers must select the appropriate mechanical ventilation procedure code based on medical record documentation. Below are some references providing guidance on when ventilation time starts and ends to ensure reporting of the correct procedure code for mechanical ventilation time:

• ICD-9-CM Official Guidelines for Coding and Reporting, AHA Coding Clinic, ICD-9-CM 4th Q, 1991

• Coding Clinic 2nd Q 1992, page 13-14

• AHA Coding Clinic for ICD-9-CM (1984 to present). Volume 27 – 3rd Quarter – Number 3 – 2010, page 3 (Ask the Editor – Ventilator Weaning) has several questions and answers on this subject.

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