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RAC Update: Incorrect Coding
In this article, we are continuing to review recent Inpatient hospital RAC findings related to incorrect coding.
Hospital Inpatient
Intracranial Hemorrhage or Cerebral Infarction
The RACs performed DRG validation on the following MS-DRGs:
064 – Intracranial Hemorrhage or Cerebral Infarction With MCC
065 – Intracranial Hemorrhage or Cerebral Infarction With CC
066 – Intracranial Hemorrhage or Cerebral Infarction Without CC/MCC
Finding: Hemiparesis is often not coded when there is sufficient documentation to code it and is incorrectly coded with insufficient documentation. The RACs review also showed that many records lacked concise documentation to support either the diagnosis of Transient Ischemic Attack (TIA) or Cerebrovascular Accident (CVA). Sometimes the documentation states TIA vs. CVA. This documentation results in the potential for providers to assign a principal diagnosis of CVA or TIA, however the documentation is not specific enough to support either one.
In one example, a patient presented to the Emergency Room with a TIA vs. CVA. Symptoms present were decreased vision, double vision, and loss of balance. The patient was noted to have right hemiparesis and neurological deficit due to acute CVA. MRA showed a 2 cm aneurysm and acute CVA near the brain. Per the progress notes, the patient continued to have hemiparesis during the hospital stay, neurological evaluation, and a physical therapy assessment. Discharge instructions were home with Occupational Therapy and Physical Therapy.
This patient was found to have an acute CVA and the physician documentation supports the principal diagnosis of 434.91 – cerebral artery occlusion with cerebral infarction. Physician documentation also supports hemiparesis as a neurological deficit due to the CVA. Hemiplegia, unspecified, code 342.90, should be assigned as an additional diagnosis. Physician documentation states the hemiparesis was not resolved by the time of discharge, but was improved.
The addition of hemiparesis as a secondary diagnosis changes the MS-DRG from 66 – Intracranial Hemorrhage or Cerebral Infarction Without CC/MCC to MS-DRG 65 – Intracranial Hemorrhage or Cerebral Infarction With CC, resulting in an underpayment.
Lessons Learned:
- Understand and apply the definition of principal diagnosis at all times when coding inpatient claims
- Refer to Coding Clinic for guidance and advice
- Review the medical record in its entirety, the discharge planning note, OT and PT notes and neurological consults
- Query the physician when clinical validation is required or if there is conflicting and/or ambiguous documentation present within the medical record
Post-Operative Anemia
For those who have been in the coding field for many years, this RAC finding will come as no surprise! The RACs continue to identify coding errors involving the coding of Post-Operative Anemia.
A DRG validation was performed by the RACs on the following MS-DRGs:
467 – Revision of Hip or Knee Replacement With CC
481 – Hip and Femur Procedures Except Major Joint With CC
486 – Knee Procedures with Principal Diagnosis of Infection With CC
488 – Knee Procedures without Principal Diagnosis of Infection With CC/MCC
Finding: Both examples below had the anemia incorrectly coded as Acute Post-Hemorrhagic Anemia. Both patients experienced Post-Operative Anemia, however the anemia was not documented as acute blood loss or due to blood loss.
On case one, an open reduction internal fixation was performed for an acute intertrochanteric fracture. No estimated blood loss was documented within the documentation provided. The progress notes and discharge summary documented the patient as having Post-Operative Anemia. The lowest hemoglobin was 8.2 on postoperative day one and the patient received 2 units of packed red blood cells.
Per Coding Clinic guidelines, Post-Operative Anemia codes to 285.9 when not specified as due to acute blood loss. As a result, 285.1 – Acute Post-Hemorrhagic Anemia, was changed to 285.9 – Anemia, Unspecified. This resulted in a DRG change from 481 - Hip and Femur Procedures Except Major Joint With CC, to 482 – Hip and Femur Procedures Except Major Joint Without CC/MCC.
On case two, a patient underwent surgery due to malunion of a femur fracture. The procedure was hardware removal deep to the bone with conversion of prior surgery to a total hip replacement. Estimated blood loss was 1500cc with 1200cc cell saver and 600cc transfused back to the patient. Lowest hemoglobin was 8.2 on postoperative day one. Progress notes on postoperative days one, two and three have a diagnosis of Post-Operative Anemia. Patient received 2 units of packed red blood cells. The discharge summary does not mention anemia.
Per Coding Clinic, Post-Operative Anemia without specification of acute blood loss codes to 285.9. As a result, code 285.1 – Acute Post-Hemorrhagic Anemia is changed to 285.9 – Anemia, Unspecified. This results in the DRG changing from 467 - Revision of Hip or Knee Replacement With CC to 468 – Revision of Hip or Knee Replacement Without CC/MCC.
Lessons Learned:
- Understand and apply the definition of principal diagnosis at all times when coding inpatient claims
- Have Coding Clinic guidelines available for reference
- Ensure there is complete documentation in the medical record to justify assignment of code 285.1
- Query the physician if there is ambiguous or conflicting information
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