DRG - INPATIENT CODING

Diagnosis Related groups (DRG’s) are the patient classification system that facilitate prospective payment to hospitals. 

After the Medicare Program was established in 1965, health care costs began to escalate.  In 1983 the retrospective payment system was replaced with the Prospective Payment System (PPS that paid for acute hospital care based on the expected costs, instead of the accrued charges.  To accomplish this, each patient discharged is categorized into a DRG.  

A physician panel at Yale University initially developed the system of DRG’s in the late 1960s as a means of “monitoring the quality of care and utilization of services in the acute hospital setting.”  

The only available medium for implementing the DRG system was the ICD-9-CM classification system, which stands for the International Classification of Diseases, Ninth Revision, Clinical Modifications.  ICD-9-CM allows you to classify disease, symptom, health problems, and procedures primarily for statistical purposes.  The system is derived from ICD, which originated over 100 years ago.  ICD-9-CM serves as a diagnostic dictionary, thus playing an essential role in the DRG system.  When a new disease or procedure is identified, it is usually assigned an existing ICD-9-CM code which best categorizes the disease or procedure.  The ICD-9-CM Coordination and Maintenance Committee evaluates the need for new ICD-9-CM codes on an annual basis.  

The data elements which define the DRG’s are routinely collected by the Health Information Management Department when a medical record is abstracted.  The information includes:

      Principal diagnosis

      Secondary diagnosis (including complications/comorbid conditions)

      Surgical procedures

      Age

      Sex

      Discharge disposition

PAYOR ID, LOCATION, AND INSURANCE

Each DRG is distinct and made up of mutually exclusive diagnoses that are separated into 25 major diagnostic categories (MDCs).  The MDCs represent a single organ system or etiology and are associated with a particular medical specialty.  No DRG contains patients in different MDCs.  Within each DRG there is further division into surgical or medical groups.

Within each MDC, the surgical procedures are ranked from highest to lowest.  The rank of a procedure is determined by the cost of the procedure.  The procedures are not ranked by the complexity of the procedure or the level of skill required to perform the procedure. 

Each DRG represent patients with similar resource intensity, resource utilization, and cost.  The hospital then, with some exceptions, is paid a flat fee for the DRG, regardless of the services actually provided or the actual resources used.  The payment represents the average cost of caring for a patient within each particular DRG.  Hospitals must be efficient and cost effective to successfully manage under this system.

Changes to the Prospective Payment System are implemented annually.  In addition to implementing revisions to the ICD-9-CM codes, DRG’s may be changed and DRG weights are revised every year on October 1st.  

Sample Coding Questions with answers

Emergency Department and Outpatient Surgery Coding Quiz
True or False:
1.) If a patient is treated for a fracture in the ED with reduction and splint application – both the splint application and fracture reduction should be assigned CPT codes. ___________
2.) If injections and infusions are not billed via the chargemaster, then coding personnel should assign CPT codes for those procedures. ______________
3.) The coding of immunizations requires only one CPT code assignment. _____________
4.) If a bone graft is taken/obtained from the primary operative site (it is not taken from a separate incision site) and is used for grafting at that same site, it should be coded with an additional CPT code. _____________
5.) Probable, possible, and rule out diagnoses may be coded on outpatient cases. ____________
Assign CPT codes and modifiers to the following:
1.) Patient presented to the ER with a 2.5 cm laceration of the left calf and a 5 cm laceration of the right upper arm. The laceration of the calf was sutured using 3-0 Vicryl to close the skin. The 5cm in length wound was explored and irrigated with 200 cc's of saline. The subcutaneous tissues were closed with 3-0 Vicryl and the skin was closed with 5-0 Maxon subcuticular sutures. ________________________________________
2.) A split graft measuring 230 square centimeters is applied to a defect on the leg. How would this procedure be reported? ______________________
3.) A left radical mastectomy for breast cancer was performed which included pectoral muscle and axillary lymph node removal. Immediately following the mastectomy procedure, a saline breast prosthesis was inserted on the left. How would this procedure be reported? __________________________________________________________


4.) Right shoulder arthroscopy with decompression of subacromial space with partial acromioplasty with coracoacromial release. An open Mumford procedure was also performed. ___________________________________________________
5.) Patient was brought to the E.D. in cardiac arrest. CPR was carried out and countershocks were applied using an external defibrillator to no avail. The patient was pronounced approximately 45 minutes following presentation to the E.D.: ___________________
6.) Nasal Endoscopic approach, bilateral: Uncinate process was removed and an ethmoidectomy was performed on the anterior portion of the ethmoid cells. The middle turbinate was then partially resected and the ostium of the maxillary sinus was accessed. An antrostomy was carried out which included removal of diseased, mucopurulent and polypoid tissues. __________________________________________
7.) Initial rhinoplasty procedure with nasal tip work, rasping/filing of bony hump, and correction of deviated nasal septum. _____________________________
8.) An incision was made on the right forearm and the radial artery isolated. The artery was clamped above and below the clot. An incision was made into the artery and the clot removed. The radial artery was repaired/closed by suture technique, followed by layered closure of the subcutaneous tissue and skin. ____________________________
9.) Repair of a single chamber lead (electrode) in a cardioverter-defibrillator. ________________________
10.) Hemorrhoidectomy was performed for extensive internal and external hemorrhoids with fissurectomy and fistulectomy: ________________________________________
11.) Meatotomy and urethral calibration and dilation was performed. The cystoscope was inserted and urethrotomy was performed internally. This was followed by a transurethral resection of the prostate. _________________________________________
12.) Cystourethroscopy with manipulation of ureteral calculus yet stone was not removed. An indwelling ureteral double J stent was inserted and left in place. ________________
13.) A cone shaped portion of tissue was removed from the cervix utilizing laser technique. This was followed by a D&C. ________________________
14.) Hysteroscopy with excision of uterine fibroids and endometrial ablation was performed. Chromotubation was carried out. This was followed by laparoscopy with lysis of adhesions around the right ovary, removal of an additional uterine fibroid tumor and left salpingectomy with oophorectomy: ____________________________________________________
15.) RACZ procedure was performed thus epidurolysis (percutaneous lysis of epidural adhesions) was utilized to dissolve scar tissue around trapped nerves in spine. ___________________________________
16.) Diskectomy, anterior, for decompression of nerve roots, thoracic, T2-T3, T3-T4: _________________________________
17.) Patient presents for a steroid injection for a herniated lumbar disk. Marcaine and Aristocort were injected into the L2-L3 space: ___________________________
18.) Patient suffers from strabismus and requires surgery. Recession of the right lateral rectus muscle with adjustable sutures was performed:___________________________
19.) Patient with a traumatic rupture of the left eardrum repaired the tympanoplasty with incision of the mastoid. Repair of ossicular chain not required. _____________________
20.) Aphakia penetrating corneal transplant: _______________________________


CASE SCENARIOS
Code the following scenarios with ICD-9-CM diagnosis and procedure, and CPT codes:
Case 1
Chief complaint: Multiple dog bites to face.
HPI: 4 year old female who was over at a friend's house when she went to pet their dog and was accidentally bitten. She sustained a 2.5cm laceration to the left upper eyelid and eyebrow, a smaller, more superficial puncture wound to the right cheek measuring approximately 1 cm and an additional puncture wound of the lower cheek measuring 5mm.
PMH: Non-contributory.
Allergies: None
Medications: None
PE: Well-developed white female, alert and oriented. HEENT: Multiple abrasions and scratches to left cheek with lacerations as described above. The left upper eyelid, eyebrow laceration will require primary repair. The puncture wounds are best left cleaned and allowed to close secondarily and these will be revised at a later date if nece3ssary. There is no injury to the orbit itself and extraocular muscles are intact.
Procedure note: The wound was prepped and draped in the usual sterile fashion and infiltrated with 1% lidocaine with epinephrine. The wounds were thoroughly irrigated. Next, the lid laceration was debrided and closed with 6-0 Vicryl and 6-0 Prolene sutures. All wounds were dressed with Polysporin ointment.
Disposition: The patient will be discharged on Augmentin 250 mg po tid and she will be seen back in follow-up in five days for suture removal and reassessment of remaining wounds.
Codes: _________________________________________________________________


Case 2
Chief Complaint: Smashed left thumb
HPI: Patient complains of an injury to the right thumb a few hours ago. The patient states that he got his finger smashed in a machine at work. Last tetanus over 5 years ago.
Allergies: None
Medications: None
ROS: The review of systems is otherwise unremarkable for major signs and symptoms of acute illness or injury for constitutional, HEENT and other significant systems reviewed, except as noted above.
PMH: Generally well.
Social History: The patient smokes 1 ½ packs a day, non-drinker.
Family History: None pertinent to the present complaint.
PE: Vital signs: Review Nurse's notes.
Finger: Left thumb. There is a laceration vertically through the 1/3 or the lateral nail involving a small portion of the tip of the finger. Nonswollen. Range of motion: full. No deformity. Neurovascular status: normal.
Treatment section:
X-ray: Left thumb: tuft fracture.
The affected area was prepped with Betadine. 0.25% Sensorcaine without epi digital block. Nail was removed. The laceration was explored to its base. There was no foreign body in the wound. Irrigated and scrubbed with normal saline and Betadine. Wound repaired with 4-0 nylon and 4-0 Vicryl. Vaseline gauze applied. Sterile dressing and aluminum finger splint applied. Ancef 1 gram IM given.
Codes: _________________________________________________________________


Case 3
Preop Dx: Basal cell carcinoma of the nasal tip.
Postop Dx: Basal cell carcinoma of the nasal tip.
Procedure performed: Wide excision of basal cell carcinoma, frozen section control of the margins and dorsal nasal flap coverage.
Anesthesia: General
Description of Procedure: Following suitable general anesthesia Lacri-Lube was placed in both eyes. The area was marked for excision, prepped with Betadine and draped sterilely. Infiltrated with Marcaine and epinephrine. After suitable waiting period, this was incised circumferentially of the 12 and 3 o'clock position marked and sent for frozen section. Frozen section revealed the margins to be clear. Following this, the dorsal nasal flap based on the right nasal labial crease vessels was marked, extended into the glabella in a V type fashion, carried down to the nasal periosteum and elevated in a left to right fashion with bleeding points being grasped and elevated. It was rotated into position and then temporarily closed. The defect was then closed with buried interrupted 4-0 undyed Vicryl followed by interrupted 5-0 Prolene. After the frozen section revealed the areas to be clear, it was then inset with 4-0 Vicryl. The margins were then trimmed and closed with 5-0 Prolene. All layers were cleansed with saline and dried. The patient tolerated the procedure well.
Codes: _________________________________________________________________


Case 4
Preoperative diagnosis: Pyloric stenosis
Postoperative diagnosis: Same with esophageal stenosis
Operative procedure: Video EGD and balloon dilation of the pylorus and esophageal dilatation to 46 with straight dilator.
Procedure: The patient was given Demerol, 50; Phenergan, 12 ½ and Versed, 2mg and Cetacaine spray. The scope was passed down with little difficulty. The GE junction was at 42 cm. The scope was advanced and had difficulty getting through the pylorus. I thought it was strictured. I was able to finally get through it and get around to the second portion of the duodenum. I then passed the 54 French balloon into the pylorus and dilated it for 30 seconds. After I removed the balloon, I could then easily pass through the pylorus. I felt there might be a slight stricture at the distal part of the esophagus. A picture was taken of it and dilated the esophagus to 54 over a guidewire. Pictures were then taken of the GE junction, also retroflexed. No other lesions were seen. The patient tolerated the procedure well and went to recovery in satisfactory condition.
Note: The French scale is not identical to the metric system of measurement. Each French unit is equal to 1/3mm; for example, a 24 French sound is equal to 8mm in diameter.
Codes: _________________________________________________________________


Case 5
Preop Dx: Right knee torn medial meniscus and proximal tibial lesion.
Postop Dx: Torn medial and lateral menisci; chondcromalacias, grad 3 of medial femoral condyle, lateral femoral condyle, and patella; proximal tibial lesion; loose body.
Procedure Performed: Diagnostic arthroscopy with debridement of partial torn lateral and partial torn medial menisci; chondroplasty of medial and lateral femoral condyles of patella; removal of loose body and fluoroscopically controlled biopsy of proximal tibia.
Anesthesia: General
Description of Procedure: The arthroscope was introduced with the scope in the anterolateral portal and the probe in the anteromedial portal. The joint was investigated, and she was found to have synovitis throughout the knee. She had grade 2 and 3 chondromalacia over most of the surface of the patella. The medial and lateral femoral condyles ahd grade 3 lesions with some delamination. There was a parrot beak type tear in the posterior horn of the medial meniscus and a degenerative type tear in the lateral meniscus. There was also a loose body in the lateral compartment which was removed with a pituitary rongeur. The motorized cutter and the Arthrocare wand were then used to take the chondral defects on the medial and lateral femoral condyles down to stable cartilage base and rim. Excess carbonization was removed with the motorized cutter. Medial and lateral menisci were then trimmed back to a stable cartilage base and rim. The opening for the lesion on the position tibia near the posterior cruciate ligament insertion was not visible from inside the joint. Chondroplasty was also performed on the patella and was taken down to stable cartilage base and rim.
The arthroscopic portion was then terminated and through an open incision, a guide pin was placed into the tibia, and under fluoroscopic control, was angled into the cystic lesion. A 6.5mm drill was then drilled just short of this, and a Craig needle was used to take a biopsy of the lesion. This was sent to pathology. The knee was instilled with 27 cc of 0.25% Marcaine with epinephrine, and she was placed in a bulky bandage. She was awakened and returned to the recovery room in satisfactory condition. Estimated blood loss was none. There were no complications.
Codes: _________________________________________________________________


Case 6
Procedure: ECCE
After routine prep and drape, a small fornix-based conjunctival flap was raised superiorly. Bleeding points were cauterized. A 7mm step incision was made above. The anterior chamber was entered under the flap with a 5531 blade. The anterior capsule was removed under Healon with a cystotome. The nucleus was emulsified in the posterior capsule. Cortex was removed with the I&A tip. The posterior capsule was vacuumed. Healon was placed in the anterior chamber and capsular bag. The wound was extended to 7mm. A 23.5 diopter, 3161B lens was positioned in the bag horizontally. The wound was closed with a shoelace 9-0 nylon suture. After the Healon was removed from the anterior chamber with I&A tip, intracameral Miostat was injected. The wound was tested for water tightness. Superior rectus suture was removed. Vasocidin ointment was applied along the lid margins. An eye shield was applied. The patient tolerated the procedure well and was taken to the recovery room in good condition.



1. F
2. T
3. F
4. F
5. F

1. 12032; 12001-51
2. 15100; 15101
3. 19200-LT; 19340-51-LT
4. 23120-RT; 29826-51-RT
5. 99291-25; 92950
6. 31254-50; 31267-51-50
7. 30420
8. 34111-RT
9. 33218
10. 46262
11. 52601
12. 52330; 52332-51
13. 57520; 58120-51
14. 58561; 58661-51-LT; 58679-51
15. 62264
16. 63077; 63078
17. 62311
18. 67311-RT; 67335
19. 69641-LT?
20. 65750

Case 1
870.0; 873.42?; 873.41; 910.0; E906.0-not CCS; E849.0-not CCS; 86.59; 12011
Case 2
927.3; 816.02; E919.9—not CCS; 86.23; 11730; 86.59?; 12001?
Case 3
173.3; 11640; 21.32; 14060?; 86.70?
Case 4
537.0; 530.3; 42.92; 44.22; 43245; 43248
Case 5
836.0; 836.1; 717.7; 717.6; 733.90; 29883; 29877-51; 20225-51; 76003; 81.47; 80.86; 80.16; 77.47
Case 6
366.9 but no pre and pst dx given!; 13.41; 13.71; 66984

CCS Exam Preparation

IMPORTANT TOPICS TO REVIEW FOR CCS PREPRATION

ICD-9-CM Diagnoses:
· Heart valve disease, with/without heart disease
· Combination codes for hypertension with heart or renal failure
· Congenital disorders treated later in life
· Late effect codes (how late is late?)
· Any section of the official guidelines that has multiple instructions (neoplasms, cardiovascular, HIV, etc.)
· Fifth digit designations (DM, osteoarthritis)
· Complications (confirming causative relationship, correct sequencing)
· Identifying infectious organisms
· Complicated wounds, crush injuries
· Differentiating primary from secondary neoplasms
· Symptoms (when it is appropriate to report them separately, inpt vs outpt use)
· Specified vs unspecified anemias
· Mental disorders (lots of changes for 2005)
· CAD if native vs. bypass vessel
· Atherosclerosis category 440.2x (explain includes notes)
· Cholecystitis (acute, chronic, with/without stones)
· OB delivery with problems (multiple codes, causes of obstructed labor)

ICD-9-CM Vol III Procedures:
· Endoscopic procedures (are there any places left where this approach is not specifically delineated?)
· Omit operative approach (laminectomy)
· Biopsy vs. excision of lesion
· PTCA (what’s included- thrombolytic, what’s not- drug eluting stent)
· Heart caths (multiple coding)
· Intestinal procedures (excisions, with/without anastomosis)
· Fracture repairs with bone grafts
· Spinal fusion (multiple coding)

CPT:
· Excision of lesions
· Skin grafts
· Breast procedures
· Bunionectomy
· Hammertoe procedures
· Bronchoscopy
· Nasal/sinus endoscopy
· Arteriovenous fistulas
· Central venous access
· Laminectomies
· Strabismus surgery
· Spinal fusion
· New procedures for control of epilepsy
· CABG
· Hemodialysis access
· Nissen fundoplasty
· Incomplete colonoscopy
· Transurethral procedures
· Repair of genital prolapse
· Scleral buckle or other type of scleral procedure instead of cataracts

Assigning POA (Present on Admission)

Be Prepared To Assign POA Indicators.

Coders must understand POA indicators and the affect on Medicare reimbursement under IPPS.

Reporting related to reporting the Present on Admission (POA) indicator. This column will go into more detail on the reporting requirements for the POA indicator and will also discuss the Centers for Medicare and Medicaid Services (CMS) identified Hospital-acquired Conditions (HAC) and their codes that, if not present on admission, will not be considered in determining the MS-DRG assignment.

POA Indicator:

POA is defined as present at the time the order for inpatient admission occurs. The purpose of the POA indicator is to differentiate between conditions present at the time of admission from those conditions that develop during the inpatient admission. Going forward you cannot code a Medicare inpatient case without also assigning the POA indicator. Therefore, coders must become as proficient in the assignment of the POA indicator as they are in capturing complications and comorbidities (CCs) and major CCs (MCCs).

Reporting Requirements.

The Deficit Reduction Act of 2005 (DRA) requires that CMS implement the reporting of the POA indicators for all diagnoses reported on Medicare claims for inpatient acute care discharges beginning Oct. 1, 2007. Critical access hospitals, Maryland waiver hospitals, long-term care hospitals, cancer hospitals and children's inpatient facilities are exempt from this requirement.

Hospitals that improperly submit the POA indicator for discharges on or after Jan. 1, 2008, will receive remittance advice remark code N36.3 informing them that they failed to report a valid POA indicator: "Alert: in the near future we are implementing new policies/procedures that would affect this determination." According to CMS when you see this remark code on your remittance advice, it is to alert you that there is a problem with your submission of POA.

Beginning with discharges on or after April 1, 2008, fiscal intermediaries will return claims to hospitals that do not include a valid POA indicator for each diagnosis on the claim. Hospitals will then have to supply the correct POA indicator and resubmit the claim.

POA Reporting Guidelines.

The POA indicator is required for the principal and all secondary diagnoses to determine whether a selected condition developed during a hospital stay. Specific instructions on how to select and report the correct POA indicator are included in the "ICD-9-CM Official Guidelines for Coding and Reporting" and in CMS Transmittal 1240.

The POA guidelines are to be used as a supplement to the ICD-9-CM Official Guidelines to facilitate the assignment of the POA indicator for each diagnosis and external cause of injury code reported on the UB-04 and 837 Institutional claim forms. CMS does not require a POA indicator for external cause of injury codes unless they are reported as an "other diagnosis."

Conditions that develop during an outpatient encounter, including emergency department, observation or outpatient surgery, are considered as POA. Medical record documentation from any provider involved in the care and treatment of the patient may be used to determine whether a condition was POA or not. In this context, the term provider means a physician or any qualified health care practitioner who can legally establish the patient's diagnosis.

A list of categories and codes exempt from POA reporting is provided in the guidelines. These codes are exempt because they represent circumstances that do not represent a current disease or injury or are always POA.

Assigning the POA Indicator.

The POA indicator is reported using one of the following variables:

Y = Yes = present at the time of inpatient admission
N = No = not present at the time of inpatient admission
U = Unknown = the documentation is insufficient to determine if the condition was present at the time of inpatient admission
W = Clinically Undetermined = the provider is unable to clinically determine whether the condition was present at the time of inpatient admission or not
1 = Unreported/Not used - Exempt from POA reporting - This code is the equivalent code of a blank on the UB-04, however, it was determined that blanks were undesirable when submitting this data via the 4010A1. The "ICD-9-CM Official Guidelines for Coding and Reporting" instructs the use of a Blank for reporting the POA for exempt codes. However, Medicare does require that "1" be reported.

When to assign Y

Assign Y for any condition the provider explicitly documents as being POA. Assign Y for conditions that were diagnosed prior to admission. For example: hypertension, diabetes mellitus, asthma. Assign Y for conditions diagnosed during the admission that were clearly present but not diagnosed until after admission occurred. Diagnoses subsequently confirmed after admission are considered POA if at the time of admission they are documented as suspected, possible, rule out, differential diagnosis or constitute an underlying cause of a symptom present at admission. Assign Y for any condition that develops during an outpatient encounter prior to a written order for inpatient admission. For example, a patient undergoes outpatient surgery. During the recovery period, the patient develops atrial fibrillation and the patient is subsequently admitted to the hospital as an inpatient. Assign Y on the POA field for the atrial fibrillation because it developed prior to a written order for inpatient admission.

When to assign N

Assign N for any condition the provider explicitly documents as not present at the time of admission. For example, a patient is admitted to the hospital for a coronary artery bypass surgery. Postoperatively he developed a pulmonary embolism. Assign N on the POA field for the pulmonary embolism. This is an acute condition that was not POA. If the final diagnosis contains a possible, probable, suspected, or rule out diagnosis, and this diagnosis was based on symptoms or clinical findings that were not POA, assign N.

When to assign U

Assign U when the medical record documentation is unclear as to whether the condition was POA. U should not be routinely assigned and should be used only in very limited circumstances. Coders are encouraged to query the providers when the documentation is unclear.

When to assign W

Assign W when the medical record documentation indicates that it cannot be clinically determined whether or not the condition was POA.

Combination Codes

If the combination code only identifies the chronic condition and not the acute exacerbation assign Y. For example, acute exacrbation of CHF Assign N if any part of the combination code was not POA. For example, obstructive chronic bronchitis with acute exacerbation and the exacerbation was not POA; viral hepatitis B progresses to hepatic coma after admission Assign Y if all parts of the combination code were POA. For example, patient with diabetic nephropathy is admitted with uncontrolled diabetes.

Obstetric Conditions.

If the obstetrical code includes more than one diagnosis and any of the diagnoses identified by the code were not POA assign N. For example, pre-eclampsia or eclampsia superimposed on preexisting hypertension assigned with code 642.7X. If the pregnancy complication or obstetrical condition was not POA assign N. For example, patient admitted in active labor. After 12 hours of labor it is noted that the infant is in fetal distress and a Cesarean section is performed. Assign N for the fetal distress.

Perinatal conditions

Newborns are not considered to be admitted until after birth. Therefore, any condition present at birth or that developed in utero is considered POA and should be assigned Y. This includes conditions that occur during delivery. For example, injury during delivery and meconium aspiration.

Congenital conditions and anomalies

Assign Y for congenital conditions and anomalies. Congenital conditions are always considered POA. For example, congenital hydrocephalus.

Codes exempt from reporting

Codes exempt from reporting are listed in the coding guidelines and are reported with the POA indicator of 1. These codes are exempt because the codes do not represent a current disease or injury or are always POA. For example, old MI, late effects of cerebrovascular disease and normal delivery.

Why is POA Important?

POA is an important because it helps differentiate between comorbidities and hospital-acquired complications. It is also important because CMS has determined that for some hospital-acquired conditions reimbursement may be affected.

Hospital-acquired Conditions

Why is Congress requiring hospitals to go to all the trouble of reporting the POA indicator? The DRA also includes a requirement that by Oct. 1, 2007, Medicare choose at least two conditions that are: High cost, high volume or both Assigned to a higher paying MS-DRG when present as a secondary diagnosis Reasonably preventable through application of evidence-based guidelines.

Beginning Oct. 1, 2008, codes representing these conditions will not be considered when calculating the MS-DRG assignment unless they were POA. In many cases, omission of these codes would result in a MS-DRG with a lower payment weight being assigned to the case. As a result, some hospital-acquired conditions could end up costing facilities much more. The POA condition, resulting in lower reimbursement, only applies when the selected conditions are the only CCs or MCCs present on the claim. If any other CC or MCC, not subject to the hospital-acquired infection provision, is present on the claim, the case will continue to be assigned to the higher-paying CC or MCC MS-DRG, and the MS-DRG assignment will not be affected.

CMS partnered with the Centers for Disease Control and Prevention (CDC) to identify potential high-volume, hospital-acquired conditions that hospitals could have reasonably prevented. Beginning on Oct. 1, 2008, cases with the following conditions will not be paid at a higher rate unless the conditions were POA.

1. Serious Preventable Event - Object Left in Surgery: CMS identifies "objects left in during surgery" as a serious preventable event. This means that this event should never occur during the health care encounter. This event is identified by diagnosis code 998.4, Foreign body accidentally left during a procedure.

2. Serious Preventable Event - Air Embolism: Air embolisms are also identified as a serious preventable event. This event is reported with diagnosis code 999.1, Complications of medical care, NOS, air embolism.

3. Serious Preventable Event - Blood Incompatibility: Although this event is rare, associated charges per case are high. There are prevention guidelines for avoiding the delivery of incompatible blood or blood products and this event should never occur. Blood incompatibility is identified by diagnosis code 999.6, Complications of medical care, NOS ABO incompatibility reaction.

4. Catheter-Associated Urinary Tract Infections (UTI): Catheter-associated UTIs are the most common hospital-acquired infection, accounting for more than 1 million cases in hospitals and nursing homes nationwide. It is estimated that hospital-acquired UTIs require one extra hospital day per patient at an estimated annual cost of $424 million to $451 million. These conditions are reported with code 996.64 Infection and inflammatory reaction due to indwelling urinary catheter and one of the following UTI codes; 112.2, 590.10, 590.11, 590.2, 590.3, 590.80, 590.81, 590.9, 595.0, 595.3, 595.4, 595.81, 595.89, 595.9, 597.0, 597.80, 599.0.

5. Pressure Ulcers: Pressure ulcers, also known as decubitus ulcers, are both a high cost and high volume condition, with more than 322,946 reported cases in FY 2006 with an average hospital charge of $40,381. CMS believes that selection of this condition will result in a closer examination of the patient's skin on admission, resulting in better quality of care. This diagnosis is identified by diagnosis codes 707.00 through 707.09

6. Vascular Catheter-Associated Infection: This condition appears to be both high cost and high volume, and there are prevention guidelines available. A new code was created effective Oct.1, 2007, to report this condition, 999.31, Infection due to central venous catheter.

7. Surgical Site Infection-Mediastinitis after Coronary Artery Bypass Graft (CABG) Surgery: In its analysis of FY 2006 discharges, CMS identified 108 cases with a secondary diagnosis of mediastinitis in patients who had CABG surgery. These patients had average hospital charges of more than $300,000. This condition is identified in cases where there is both diagnosis code 519.2, Mediastinitis, and one or more of the CABG procedures codes 36.10 through 36.19 on the same claim.

8. Hospital-Acquired Injuries-Fractures, Dislocations, Intracranial Injury, Crushing Injury, Burn and Other Unspecified Effects of External Causes: CMS has not yet determined the codes that will be used to identify these conditons. They will be included in the FY 2009 proposed IPPS rule for comment.

Conditions being considered for FY2009CMS also indicated that they are evaluating the following conditions. They may be included in the FY 2009 proposed IPPS rule for comment

1. Ventilator Associated Pneumonia (VAP)
2. Staphylococcus Aureus Septicemia
3. Deep Vein Thrombosis (DVT)/ Pulmonary Embolism (PE).

This article only discussed the Medicare requirements for POA and hospital-acquired conditions. There are some state specific requirements regarding the reporting of the POA indicator. To ensure compliance with any state-specific POA reporting requirement it is important to check with the appropriate state hospital association.

Take some time now to review in detail the FY 2008 ICD-9-CM Official Guidelines for Coding and Reporting related to POA at www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide07.pdf . You may also want to review the CMS Web site on Hospital-acquired Conditions at www.cms.hhs.gov/HospitalAcqCond/.

Coding clinics on POA indicator

AHA Coding Clinicâ for ICD-9-CM, 3Q 2008, Volume 25, Number 3, Page 20
Notice
Section 5001(c) of Pub. L. 109-71 requires the Secretary of the Department of Health and Human Services to identify a list of hospital-acquired conditions and to collect information regarding such conditions. The Department of Health and Human Services' Centers for Medicare & Medicaid Services (CMS) has developed a process for hospitals to submit a Present on Admission (POA) indicator with each diagnosis. For more specific instructions on Medicare POA indicator reporting instructions, refer to

http://www.cms.hhs.gov/HospitalAcqCond/02_Statute_Regulations_Program_Instructions.asp#TopOfPage

The American Hospital Association (AHA) and the Centers for Medicare & Medicaid Services (CMS) are collaborating on the design of a mechanism to receive, analyze and respond to questions about POA coding. In the interim, the Cooperating Parties for ICD-9-CM have developed responses to the most frequently asked POA indicator reporting questions.

AHA Coding Clinicâ for ICD-9-CM, 1Q 2009, Volume 26, Number 1, Page 19
Frequently Asked POA Questions

Clarification: Stage II Pressure Progressing to Stage III

Question: Coding Clinic Fourth Quarter 2008, page 194 stated that a stage II pressure ulcer, which was present on admission, and progresses to become a stage III pressure ulcer during the stay is reported as “Yes” for the present on admission (POA) indicator. However, the POA indicator is reported for conditions present at the time of inpatient admission. It appears inconsistent to report a Stage III pressure ulcer as present on admission since the pressure ulcer gradually deteriorated during the hospital stay. Could Coding Clinic please clarify this issue for coders and clinical teams that rely on this guidance?

Answer: In terms of coding and POA reporting, a pressure ulcer is only coded and reported once at the highest stage. The information published in Coding Clinic Fourth Quarter 2008, page 194, instructing to report a Stage II pressure ulcer that progresses to a Stage III as present on admission is correct. The pressure ulcer was present on admission; therefore, the POA should be yes. This advice is consistent with the National Quality Forum (NQF) endorsed measures. The NQF established a standardized set of serious reportable events also called never events. The list of serious reportable events excludes the progression of a pressure ulcer from stage II to Stage III, if stage II was recognized upon admission.

The NQF is an organization created to develop and implement a national strategy for health care quality measurement and reporting. Please refer to the NQF website for additional information about “Serious Reportable Events in Healthcare”:
AHA Coding Clinicâ for ICD-9-CM, 3Q 2008, Volume 25, Number 3, Page 20-21
Frequently Asked POA Questions

Question: We have heard that the documentation of a pressure ulcer has to be completed within two calendar days of admission. Also, we often query the physician post discharge if the coder cannot make the determination of POA with the documentation in the record. Will this process still be allowed in FY 2009?

Answer: There is no required timeframe as to when a provider (per the definition of “provider” used in the Official Guidelines for Coding and Reporting) must identify or document a condition to be present on admission. In some clinical situations, it may not be possible for a provider to make a definitive diagnosis (or a condition may not be recognized or reported by the patient) for a period of time after admission. If at the time of code assignment, the documentation is unclear as to when a condition developed, it is appropriate to query the physician for clarification.

http://www.qualityforum.org/pdf/reports/sre/txsrepublic.pdf
AHA Coding Clinicâ forICD-9-CM, 4Q 2008, Volume 25, Number 4, Page 194
Frequently Asked POA Questions

Question: A patient is admitted to the hospital with a stage II pressure ulcer of the heel. During the hospitalization, the pressure ulcer worsens and becomes a stage III. Based on the new Official Coding Guidelines, we would be assigning the code for the highest stage for that site. What would be the correct POA indicator assignment for the stage III code?

Answer: Assign “Y” to the pressure ulcer stage III code since this code is referring to a pressure ulcer that was present on admission rather than a new ulcer.

AHA Coding Clinicâ for ICD-9-CM, 1Q 2010,Volume 27, Number 1, Pages 18-19
Frequently Asked POA Questions

Question: A 70-year-old female with chronic obstructive pulmonary disease (COPD) was admitted with an acute exacerbation of COPD. The patient presented to the hospital with acute respiratory distress and hypoxia. On day two, she was transferred to the intensive care unit (ICU) and placed on mechanical ventilation to treat acute respiratory failure. The patient's respiratory issues were stabilized and the patient was discharged home. What are the appropriate POA indicators?

Answer: For coding and reporting purposes, both the COPD exacerbation and the acute respiratory failure would be separately coded.
The POA indicator for the acute exacerbation of the COPD is “Y.” If the health record documentation is not clear regarding whether respiratory failure was present on admission, query the provider for clarification. If the provider responds that the respiratory failure developed after admission, assign a POA indicator of “N.” If the provider cannot determine whether the respiratory failure was present on admission, assign a POA indicator of “W.”

Question: The patient, a 76-year-old male, presented to the emergency department (ED) with a three-day onset of respiratory distress. In the ED, the patient rapidly deteriorated, developing acute respiratory failure which led to his admission. He was admitted to the intensive care unit of the hospital and placed on mechanical ventilation. The patient was discharged following an uneventful hospital course. What are the POA indicators for this case?

Answer: The principal diagnosis would be acute respiratory failure since this was the reason the patient was admitted to the hospital. A separate code for respiratory distress would not be reported.
The POA indicator for the acute respiratory failure is “Y” since the acute respiratory failure developed prior to admission.

AHA Coding Clinicâ for ICD-9-CM, 3Q 2008, Volume 25, Number 3, Page 21
Frequently Asked POA Questions

Question: Do we need to assign a POA indicator to E-codes?

Answer: While many E codes are exempt from POA reporting (refer to the list of exempt codes on the Official Guidelines for Coding and Reporting) and will be reported with an “1” for Medicare, many other E codes will require reporting of the POA indicator if they are reported among the secondary diagnoses. Examples of the code ranges requiring POA reporting are Accidental poisonings by drugs, medical substances and biologicals (E850-E858), and Drugs, medicinal and biological substances causing adverse effects in therapeutic use (E930-E949), among others.

AHA Coding Clinicâ for ICD-9-CM, 2Q 2010, Volume 27, Number 2, Page 14
Frequently Asked POA Questions

Question: A patient is admitted with a subarachnoid hemorrhage following an injury. At the time of admission there was no mention of loss of consciousness. However, after admission the patient lost consciousness for several hours. We assigned code 852.03, subarachnoid hemorrhage following injury without mention of open intracranial wound, with moderate [1-24 hours] loss of consciousness, as the principal diagnosis. What is the appropriate POA indicator since the patient lost consciousness after admission?

Answer: Assign POA indicator “Y” since the injury occurred prior to admission. Loss of consciousness is part of the natural history of the disease process. In addition, the POA guideline governing combination codes does not apply here, since this is not a combination of diagnoses. The skull fracture (800-804) and intracranial injury (850-854) categories are unique, so this advice only applies to these categories.

Medicare Services

Medicare police given to:

A. with People age 65 or older,
B. People under age 65 certain disabilities, and
C. People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

Medicare has:

Part A Hospital Insurance - Most people don't pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits.

Part B Medical Insurance - Most people pay a monthly premium for Part B. Medicare Part B (Medical Insurance) helps cover doctors' services and outpatient care. It also covers some other medical services that Part A doesn't cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.

Prescription Drug Coverage - Most people will pay a monthly premium for this coverage. Starting January 1, 2006, new Medicare prescription drug coverage will be available to everyone with Medicare. Everyone with Medicare can get this coverage that may help lower prescription drug costs and help protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance. Private companies provide the coverage. Beneficiaries choose the drug plan and pay a monthly premium. Like other insurance, if a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later.
Two types:

1. Medicare part A.

2. Medicare part B.

Medicare part A: Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Certain conditions must be met to get these benefits.
Cost: Most people don’t have to pay a monthly payment, called a premium, for Part A. This is because they or a spouse paid Medicare taxes while working. If a beneficiary doesn't get premium-free Part A, they may be able to buy it if they (or their spouse) aren’t entitled to Social Security, because they didn’t work or didn’t pay enough Medicare taxes while
working, are age 65 or older, or are disabled but no longer get free Part A because they returned to work.
If they have limited income and resources, their state may help them pay for Part A.

Medicare part B: Medicare Part B (Medical Insurance) helps cover doctors’ services and outpatient care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.
Cost: The Medicare Part B premium each month ($78.20 per month in 2005). In some cases, this amount may be higher if the beneficiary didn’t sign up for Part B when they first became eligible.
Caution: If the beneficiary didn’t take Part B when they were first eligible, the cost of Part B will go up 10% for each full 12-month period that they could have had Part B but didn’t sign up for it, except in special cases. They will have to pay this penalty as long as they have Part B.
They also pay a Part B deductible each year before Medicare starts to pay its share. The Part B deductible for 2005 is $110.00. The beneficiary may be able to get help from their state to pay this premium and deductible.
Medicare deductible and premium rates may change every year in January.

CCS Exam

The CCS (Certified coding specialist) exam of AHIMA is conducted through Pearson VUE authorised test centers from January 2011.