RAC Begins Complex DRG Validation Audits

This concept is also pertinent for the issues involving procedures unrelated to the principal diagnosis DRGs, she says. "These DRGs have high relative weights and should be encountered infrequently. They have long since been a target for payers because of their high weights, as well as the unlikelihood of their occurrence, especially these days with admission criteria and procedures being done more commonly in the outpatient setting."

For example, consider the following weights for 2010 of some of the issues Connolly is targeting:

• MS-DRG 981, Extensive OR procedure unrelated to principal diagnosis with MCC: Weight 5.0389


• MS-DRG 982, Extensive OR procedure unrelated to principal diagnosis with CC: Weight 2.8954


• MS-DRG 983, Extensive OR procedure unrelated to principal diagnosis without CC/MCC: Weight 1.8072


• MS-DRG 987, Nonextensive OR procedure unrelated to principal diagnosis with MCC: Weight 3.4020


• MS-DRG 988, Nonextensive OR procedure unrelated to principal diagnosis with CC: Weight 1.7836


• MS-DRG 989, Nonextensive OR procedure unrelated to principal diagnosis without CC/MCC: Weight 1.0358

Septicemia and ventilation DRGs

"Septicemia is a diagnosis that has been problematic for a long time because coders often misunderstand the ICD-9 Guidelines for Coding and Reporting as it pertains to the sequencing of the assigned codes," says McCall. "This is especially true with sepsis as it relates to septicemia and other underlying infections that can cause sepsis. Many read the guidelines as saying septicemia is always the principal diagnosis when in fact that may not be the case depending on the documentation."

For example, in an admission when the patient has sepsis because of an underlying infection (e.g., pneumonia) the sequencing could change depending on whether the physician's documentation states that the patient also had septicemia, she explains. The instructional note for code 995.91 (sepsis) states that coders should sequence the underlying infection first, which could be pneumonia (code 486) or septicemia (code 038.xx), depending on the circumstances surrounding the admission.

"Ventilation is also tricky," says McCall. "This is another area that has specific guidelines on when it can be reported, and coders have to deal with the time-counting aspect as well. And for the medical DRGs, it makes sense to target those with CCs or MCCs like cirrhosis and alcoholic hepatitis because a common symptom and associated sign is mental confusion, which could be inaccurately coded as an encephalopathy [348.xx are MCCs] or malnutrition (severe protein calorie is a MCC)," McCall says.

Connolly has also provided descriptions of each of the new issues, along with references for providers who are looking to find more information on any of the topics.