Dan Kaelin, M.D. Vascular Surgery Associates Tallahassee, Fl — Chad Linville, ARNP, DNP — W.L. Gore I am not a coder nor do I understand fully the DRG coding system — In 1982, Congress mandated the creation of a prospective payment system (PPS) to control costs. Congress looked at the success of State rate regulation systems in controlling costs and mandated the implementation of a prospective payment system model that had been successful in several States. This system is a per-case reimbursement mechanism under which inpatient admission cases are divided into relatively homogeneous categories called diagnosis-related groups (DRGs). In this DRG prospective payment system, Medicare pays hospitals a flat rate per case for inpatient hospital care so that efficient hospitals are rewarded for their efficiency and inefficient hospitals have an incentive to become more efficient. — DRGs classify all human diseases according to the affected organ system, surgical procedures performed on patients, morbidity, and sex of the patient. — The classification also accounts for up to eight diagnoses in addition to the primary diagnosis, and up to six procedures performed during the stay. Too Difficult to describe — Evaluate hospital coding for aortic endografts — Compare coding to a retrospective review of records — Third party evaluation of results — Suggest plan for improvement with assumption we were not doing it right — Continued technology advances must be funded (fenestrated time/cost) — Hospitals facing decrease reimbursement — Non-clinical personnel making device purchasing decisions — Physicians and hospitals frequently detached from each other relative to billing — Two Diagnosis Related Groups (DRG) used by hospitals to bill for surgical repair of AAA using endografts. — DRG 237 is used when the patient has a documented medical history that includes one of the 1,623 ICD-9 codes considered a major complicating condition (MCC). — DRG 238 is used when they do not. — Average charge per case — DRG 238 - $81,178 — DRG 237 - $157,569 — Percentage of cases coded — DRG 238 – 89.7% — DRG 237 – 10.3% Hospital DRG 238 DRG 237 TMH 89.7 10.3 1 83.3 16.6 2 92.9 7.1 3 95 5 4 91.3 8.7 5 89.5 10.5 6 87.3 12.7 7 100 0 8 84.6 15.4 Hospital DRG 238 237 DRG 238 237 TMH $81,000 10.3 $158,000 89.7 1 $80,000 16.6 $109,000 83.3 2 $123,000 7.1 $219,000 92.9 3 $73,000 5 $126,000 95 4 $95,000 8.7 $134,000 91.3 5 $118,000 10.5 $201,000 89.5 6 $107,000 12.7 $153,000 87.3 7 $141,000 0 100 $0 8 $77,000 15.4 $137,000 84.6 — EMR review of medical records — 114 patients (10/1/2008 to 9/30/2011) — Only surgeries completed by a surgeon from VSA at TMH — Clinical notes, operative notes, problem lists and documentation from other providers and healthcare facilities were reviewed from VSA’s EMR, TMH EMR and community HIE. — Two review passes Performed — First conservative — Second aggressive — Exhaustive review of the images for dissection not completed in this review — 15 of 114 patients (13.2%) appeared to have a MCC adequate to bill DRG 237 — This compares to 8.8% billed by TMH for the same patient population. — Most common diagnoses were AAA rupture or dissection and respiratory failure following surgery. Co-morbidity AAA Rupture or Dissection (441.3, 443.22) Respiratory Failure Following Surgery (518.51) Cardiac Arrest (427.5) Acute on Chronic Heart Failure (428.23, 428.43) Acute MI (410.91) End Stage Renal Disease (585.6) Postoperative Shock (998.01) Vascular Myelopathies (336.1) Total Frequency 3 3 2 2 2 1 1 1 15 Rate 20.0% 20.0% 13.3% 13.3% 13.3% 6.7% 6.7% 6.7% — Five cases did not match the review — Two patients identified as DRG 238 were billed by the hospital without using a DRG code. — One billed for DRG 226 (cardiac defibrillator implant without catheterization and with MCC) — One billed for DRG 254 (other vascular procedures w/o MCC) — One was identified by the vascular surgeon as having an iliac dissection, which is considered a MCC, but was billed by the hospital using DRG 238 — 34 of 114 patients (29.8%) appeared to have a MCC adequate to bill DRG 237 — This compares to 8.8% billed by TMH for the same patient population. — Myocardial infarction and stroke became the leading MCC qualifying diagnosis codes. Co-morbidity Myocardial Infarction (410.11, 410.41, 410.51, 410.91) Stroke (433.11, 434.91) Other (336.1, 415.19, 482.9, 530.21, 585.6, 998.01) Acute on Chronic Heart Failure (428.23, 428.43) AAA Rupture or Dissection (441.02, 441.3, 443.22) Respiratory Failure Following Surgery (518.51) Cardiac Arrest (427.5) Total Frequency 9 6 6 4 4 3 2 34 Rate 26.5% 17.6% 17.6% 11.8% 11.8% 8.8% 5.9% — More than the 8 week rule used if felt a risk factor for the procedure — Example — MI in last 90 days preop (outside 8 week window) — Stroke felt to effect recovery from procedure — Bleeding ulcer within 30 days of procedure — Price Waterhouse — Reviewed all our findings both passes — 24 additional patients we felt should have been coded with MCC they agreed with 7 — Details sent to hospital for review — Combination of lack of hospital documentation and coding error — Dissection of Aorta/Iliac — Pulmonary Insufficiency — Injury to inferior mesenteric artery — Injury to just about any vessel — C-diff — Diarrhea of presumed infectious origin — Lung Cancer — Clotting disorder — ETOH withdrawal — Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I through stage IV, or unspecified — Hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic kidney disease stage I through stage IV, or unspecified — A-flutter — SVT — Chronic systolic heart failure — Arterial embolism — Phlebitis and thrombophlebitis of other sites — Lower extremity ulcer — Injury to saphenous vein — BMI > 40 — 5 ft 9 in and 270 lbs — Coding is complicated — Significant disconnect between hospital coding and physician documentation — Important outside documentation not available to coders — Lack of physician understanding of the rules — Exposes hospital to reduction in reimbursement and potential audit failure — Working with hospital to have more documentation available to coders — Educate physicians on important documentation points to include — Continue to educate CMS on diagnoses that effect care and outcomes