REVENEWS


RAC Findings

Happy New Year! G2N wishes you a year of health, happiness and prosperity! In this article, we will learn about another RAC finding that affects Inpatient Hospitals.

Improper Coding of Coronary Bypass with Percutaneous Transluminal Coronary Angioplasty (PTCA) with Major Complications and Comorbidities (MCCs) MS-DRGs 231, 233, 235
The example below provides reasons for coding changes that resulted in an MS-DRG change. The change in code assignments is to align provider payments with Medicare guidelines for the presence of diagnoses while making sure diagnoses are properly sequenced, coded and clinically validated.

Case A: A 68 year old patient was admitted to undergo a Coronary Artery Bypass Graft x 3 due to 3 vessel Coronary Artery Disease (CAD). Per the Discharge Summary and History and Physical (H&P), the patient had previously been admitted due to flash pulmonary edema and had also ruled in for a Myocardial Infarction (MI). During the previous admission, the patient was treated and optimized. He needed some time at home to take care of some personal business before his current admission for a CABG x 3. Following his CABG x 3 during his current admission, he was discharged to home.

Lessons Learned
The unspecified acute lung edema, ICD-9-CM Diagnosis Code 518.4, was incorrectly assigned. This condition was not documented as a current problem on this admission for a CABG x 3 and it was not treated or evaluated. Therefore, it did not meet criteria to report it as a secondary diagnosis and it was deleted for this admission. This condition was treated and optimized on the patient’s prior admission before discharge.

This change in coding resulted in a change from MS-DRG 235 (Coronary Bypass Without Cardiac Cath With MCC) to MS-DRG 236 (Coronary Bypass Without Cardiac Cath Without MCC). The result was an overpayment.

  • Always review the Official Coding Guidelines for the selection of Principal Diagnosis and chapter specific guidelines to ensure proper code assignment.
  • The condition that after physician study is determined to be chiefly responsible as the cause for the current admission should be sequenced as the Principal Diagnosis.
  • Review of Coding Clinic is pertinent for advice and guidance.

For additional information, click on the link below:

http://www.cms.gov/MLNProducts/Downloads/MedQtrlyComp_Newsletter_ICN907163.pdf