Exploring DRGs 014 and 088, Coding Tips and Techniques

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Exploring DRGs 014 and 088, Coding Tips and
Techniques

• Eva Gregorek, RHIT, CCS, HIM Analyst
• Northeast Health-Troy, NY
• April 14, 2005

An IPRO and Hospital/Professional Association
Collaborative Presentation
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Why DRG 14?(All data shown below is for NYS, not
the Nation)

• One of the highest volume DRGs
• Approx 14k discharges annually
• Approx Medicare monies 81 million
• Payment Error Data
• 22.4 of reviews denied for DRG/Coding
• Potentially 18 million in error annually

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Why DRG 88?(All data shown below is for NYS, not
the Nation)

• One of the highest volume DRGs
• Approx 22k discharges annually
• Approx Medicare monies 91 million
• Payment Error Data
• 10.6 of reviews denied for DRG/Coding
• Potentially 10 million in error annually

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Issues with DRG 014 and 088

• These DRGs have proven challenging due to
• ICD-9-CM indexing
• Complexity of medical conditions
• Overlapping nature of classification
• Physician documentation

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DRG 014 - Intracranial Hemorrhage or Cerebral
Infarction

• Some conditions that fall into DRG 014
• Cerebral infarction NOS
• Subarachnoid hemorrhage
• Stroke effective 10/01/04
• CVA effective 10/01/04
• Pre-cerebral/Cerebral artery occlusion with
  infarction
• Cerebral thrombosis with infarction
• Cerebral Embolism with infarction

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Definition of Stroke/Infarction

• A stroke - a neurological deficit with sudden
  onset due to vascular disease. It is a clinical
  (not pathological) diagnosis.
• Cerebral Infarction - acute ischemia with
  localized hypoxic injury with necrosis
• Cornell University Medical Center
• Stroke and infarction can be caused by
• - Embolism
• - Thrombosis
• - Occlusion

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Stroke/Infarction Statistics

• Every 45 seconds, someone in America has a
  stroke. About 700,000 Americans will have a
  stroke this year. Stroke is our nation's No. 3
  killer and a leading cause of severe, long-term
  disability.
• In 2004 the estimated direct and indirect cost of
  stroke is 53.6 billion.
• 50 percent had some one-sided paralysis
• 30 percent were unable to walk without some
  assistance

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Stroke/Infarction Statistics (continued)

• 26 percent were dependent in activities of daily
  living (grooming, eating, bathing, etc.)
• 19 percent had aphasia (trouble speaking or
  understanding the speech of others)
• 35 percent had depressive symptoms
• 26 percent were institutionalized in a nursing
  home
• from the American Stroke Association a division
  of the Americal Heart Association

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Clinical Documentation
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Risk Factors for Stroke

• High blood pressure
• Tobacco use
• Diabetes mellitus
• Carotid or other artery disease
• Atrial Fibrillation
• Other heart disease
• Transient ischemic attacks(TIAs) "warning
  strokes"
• High cholesterol levels
• Heredity
• Gender

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Signs and symptoms

• Sudden onset of
• numbness or weakness of the face, arm or leg,
  especially on one side of the body
• confusion, trouble speaking or understanding
• trouble seeing in one or both eyes
• trouble walking, dizziness, loss of balance or
  coordination
• severe headache with no known cause

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Diagnostics

• CT Scan
• MRI
• EEG
• Blood flow testing
• B-mode imaging
• Doppler testing
• Duplex scanning
• Angiography

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Treatment

• Ischemic stroke is treated by removing
  obstruction and restoring blood flow to the
  brain.
• In hemorrhagic stroke treatment is directed
  towards prevention of rupture and bleeding of
  aneurysms and arteriovenous malformations.

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Treatment (continued)

• Ischemic Stroke
• Acute Treatment
• Clot-busters, e.g., tPA
• must be administered within a three-hour window
  from onset of symptoms for most effective use
• only 3 to 5 percent of those reach the hospital
  in time to be considered for this treatment
• Preventative Treatment
• Anticoagulants/Antiplatelets
• Carotid Endarterectomy
• Angioplasty/Stents

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Treatment (continued)

• Hemorrhagic Stroke
• Surgical Intervention
• Surgical treatment is often recommended to either
  place a metal clip at the base, called the neck,
  of the aneurysm or to remove the abnormal vessels
  comprising an Arteriovenous Malformation (AVM).
  
• Endovascular Procedures, e.g., "coils"
• less invasive and involves the use of a catheter
  introduced through a major artery in the leg or
  arm
• catheter is guided to the aneurysm or AVM where
  it deposits a mechanical agent, such as a coil,
  to prevent rupture

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Effects of a Stroke

• The effects of a stroke depend on several factors
  including the location of the obstruction and how
  much brain tissue is affected. However, because
  one side of the brain controls the opposite side
  of the body, a stroke affecting one side will
  result in neurological complications on the side
  of the body if affects.

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Effects of a Stroke (continued)

• Right Brain-the left side of the body and the
  right side of the face will be affected, which
  may produce any or all of the following
• Paralysis on the left side of the body
• Vision problems
• Quick, inquisitive behavioral style
• Memory loss

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Effects of a Stroke (continued)

• Left Brain -the right side of the body and the
  left side of the face will be affected, producing
  some or all of the following
• Paralysis on the right side of the body
• Speech/language problems
• Slow, cautious behavioral style
• Memory loss

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Coding Tips and Techniques
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• Effective 10/01/04 the ICD-9-CM Coordination and
  Maintenance Committee made the following change
• - Stroke and CVA were reindexed to 434.91 -
  cerebral artery occlusion,unspecified, with
  cerebral infarction for the following reasons
• coding of stroke and CVA had been problematic
• physicians use the terms stroke, CVA, and
  cerebral infarction interchangeably
• to promote uniformity of coding and statistical
  data

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Alphabetic index revision effective 10/01/04
Accident,accidental-see also condition Revise
cerebral(see also Disease, cerebrovascular,
acute) 434.91 Revise cerebrovascular
(current)(CVA)(see also Disease,cerebrovascul
ar, acute) 434.91 Add embolic
434.11 Add ischemic 434.91 Add thrombotic
434.01
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Tabular Revision effective 10/01/04 Add 436 Acute
, but ill-defined cerebrovascular
disease Delete Cerebrovascular
accident CVA NOS Delete Stroke Add
Excludes cerebrovascular accident (434.91)
embolic (434.11)
hemorrhagic(430, 431,
432.0-432.9)
thrombotic(434.01)
stroke (ischemic) (434.91)
embolic (434.11)
hemorrhagic(430, 431, 432.0-432.9)
thrombotic(434.01)
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• Regardless of DRG assignment it is important to
  classify conditions correctly using the following
  guidelines
• Cerebral Infarction/stroke/cerebrovascular
  accident(CVA)
  2005 Official Coding Guidelines
• The terms stroke and CVA are often used
  interchangeably to refer to a cerebral infarction
• Code 436 should not be used when documentation
  states stroke or CVA

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• Post-operative cerebrovascular accident 2005
  Official Coding Guidelines
• Assign code 997.02, iatrogenic cerebrovascular
  infarction or hemorrhage
• Clear cause and effect documentation must be
  present
• Assign secondary code from 430-432 or 433 or 434
  with a fifth digit of "1" should also be assigned
• Code 436 should not be used as a secondary code
  due to re-indexing effective 10/01/04

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• Late effects of Cerebrovascular Disease
• 2005 Official Coding
  Guidelines
• Used to indicate conditions classifiable to
  430-437 as the cause of the late effect
• May be present at onset or any time after the
  acute condition
• Codes from 438 with 430-437
• May be used if the patient has a current acute
  event and deficits from an old CVA
• Code V12.59
• Should be used when a history of cerebrovascular
  disease with no deficits
• Do not use a code from 438 to describe this

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• Neurological deficits of current
  stroke Coding Clinic 2nd Quarter 1989
• Do not code deficits due to current stroke if
  they resolve prior ro discharge
• Assign codes for the deficits if they are still
  present at discharge
• Example A patient admitted with an embolic
  cerebral infarction and still has hemiplegia at
  discharge. Assign codes 434.11 and 784.3

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• Stroke due to arterial occlusion
  Coding Clinic, Fourth
  Quarter 1993 Page 38 to 39
• If a stroke (cerebral infarction) is due to an
  occlusion of the cerebral or precerebral
  arteries, codes from category 433.xx, Occlusion
  and Stenosis of Precerebral Arteries, or 434.xx,
  Occlusion of Cerebral Arteries, should be used.
• The physician must clearly indicate the cause and
  effect relationship.

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• Lacunar Infarction
  Coding Clinic, Second Quarter
  1996 Page 5
• Assign code 434.91, Cerebral artery occlusion,
  unspecified, with cerebral infarction, for the
  diagnosis of lacunar infarction.
• Embolic hemorrhagic infarct of temporal lobe
  Coding Clinic, Third Quarter 1997 Page 11
• Assign code 434.11, Occlusion of cerebral
  arteries, cerebral embolism, with cerebral
  infarction The hemorrhage is a component of the
  occlusion, therefore, do not assign code 431,
  Intracranial hemorrhage, as an additional code.

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• Impending CVA, cerebral ischemia, transient
  ischemic attack
• Assign code from category 435
• Use 435.9 unless documentation supports a more
  specific code from this category
• These codes map to DRG 524 - transient ischemia

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Clinical Example 1

• 68 year old woman experienced dizziness and
  severe headache. The patient had a previous CVA
  with residual apraxia. She was brought by
  ambulance to the hospital where a CT scan showed
  acute cerebral infarction. The attending
  physician documents an acute cerebral infarction
  due to cerebral thrombosis. At discharge the
  patient has aphasia.
• - Codes 434.01 - cerebral thrombosis w/
  infarction 784.3 -
  aphasia 438.81 - late effect of CVA with
  apraxia

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Clinical Example 2

• 68 year old woman experienced dizziness and
  severe headache. The patient had a previous CVA
  with residual apraxia. She was brought by
  ambulance to the hospital where a CT scan was
  negative for acute cerebral infarction. The
  neurologist documents TIA and the attending
  physician documents CVA in the discharge summary.
  CVA is not mentioned in any other area in this 5
  day stay medical record.
• - Query the physician due to lack of consistency
  in the record

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DRG 088
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DRG 088 - Obstructive Lung Disease

• Some conditions that fall into DRG 088
• Chronic obstructive bronchitis
• COPD with acute bronchitis
• Acute and chronic obstructive bronchitis
• COPD
• COPD with acute exacerbation

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Definition of obstructive lung diseases

• Asthma - pulmonary disease characterized by
  airway inflammation, reversible airway
  obstruction, manifested by hyper-responsive
  airway
• Bronchiectasis - chronic dilation of the bronchi
  or bronchioles
• Emphysema - abnormal permanent enlargement of the
  airspaces distal to the terminal bronchiole with
  destruction in their walls and reduction in their
  quantities

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Definition of obstructive lung diseases
(continued)

• Bronchitis - inflammation of the mucus membrane
  of the bronchial tubes
• Chronic Bronchitis - condition characterized by
  cough, hypersecretion of mucus, and expectoration
  of sputum over a long period of time
• Acute Bronchitis - acute inflammation if the
  bronchus, generally self limited and with
  complete healing and return of function
• COPD - a disorder characterized by reduced
  maximal expiratory flow and slow forced emptying
  of the lungs

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Clinical Documentation
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Signs and symptoms

• persistent, diffuse wheezing, diminished breath
  sounds, or prolonged expirations
• increased dyspnea, breathlessness, or tachypnea
• chronic productive cough
• increased sputum production
• bronchospasms

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Signs and symptoms (continued)

• speech difficulty
• use of accessory respiratory muscles
• clubbing of nails
• orthopnea
• hypoxemia
• tachycardia

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Diagnostics

• chest x-ray
• arterial blod gases
• pulmonary function test

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Treatment

• Treatment is directed towards controlling the
  symptoms and eliminating any underlying cause for
  any exacerbation. May consist of
• medication therapy - antibiotics,
  anti-inflammatory, anticholinergics,
  bronchodilators, mucolytics, or diuretics
• airway clearance
• oxygen therapy

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Treatment (continued)

• Prevention
• smoking cessation
• pulmonary rehab
• respiratory physical therapy

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Coding Tips and Techniques
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• As always, physician documentation must clearly
  indicate the obstructive lung condition
• Watch for conflicting/contradictory
  documentation
• Do not code solely on radiology reports
• Always look for correlation between the attending
  physician and other physician documentation
• Consistency of documentation is critical.

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Effective October 1, 2004, a new code has been
created to report acute bronchitis when
accompanied by chronic obstructive pulmonary
disease (COPD). 466 Acute bronchitis and
bronchiolitis 466.0 Acute
bronchitis Add Excludes acute bronchitis with
chronic obstructive pulmonary
disease(491.22)
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491 Chronic bronchitis 491.2
Obstructive chronic bronchitis 491.21
With (acute) exacerbation Delete Acute and
chronic obstructive bronchitis Delete Emphysema
with acute and chronic bronchitis New code
491.22 With acute bronchitis
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492 Emphysema 492.8 Other emphysema Exclude
s emphysema Revise with chronic bronchitis
(491.20 - 491.22) 493 Asthma
493.2 Chronic obstructive asthma Revise
Excludes chronic obstructive bronchitis
(491.20 - 491.22)
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496 Chronic airway obstruction, not
elsewhere classified Excludes chronic
obstructive lung diseaseCOPDspecified
(as)(with) Revise bronchitis (491.20 -
491.22) Revise with emphysema (491.20 - 491.22)
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(continued)

• Watch for specificity
• Subcategory 491.2 Obstructive chronic bronchitis
• 491.20 - without exacerbation
• 491.21 - with (acute) exacerbation
• 491.22 - with acute bronchitis
• Category 493 - Asthma
• 5th digits
• 0 - unspecified
• 1 - with status asthmaticus
• 2 - with (acute) exacerbation

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• Category 494 - Bronchiectasis
• 494.0 - without exacerbation
• 494.1 - with acute exacerbation
• Must specify acute
• Emphysema
• COPD with Emphysema
• Assign 492.8
• COPD with Emphysema with (Acute) Exacerbation
• Assign 491.21
• COPD with Emphysema with Acute Bronchitis
• Assign 491.22
• Emphysema with Acute Bronchitis
• Assign 466.0 and 492.8
• Assign 466.0 as principal diagnosis

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• COPD and asthma Official Coding
  Guidelines 2005
• - Code 496 is a nonspecific code that should only
  be used when the medical record does no specify
  the type of COPD
• - all asthma codes are coded under category 493
• Acute exacerbation of chronic obstructive
  bronchitis and asthma
• - these codes differentiate uncomplicated cases
  and those in acute exaceration
• - acute exacerbation is a worsening or
  decompensation of a chronic condition

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• Overlapping nature of COPD and asthma
• review all codes and instructional notes in the
  code book due to the many variations of the codes
• COPD and bronchitis
• Assign code 491.22 to describe COPD with acute
  bronchitis. It is not necessary to assign 466.0
  - acute bronchitis.
• COPD with (acute) exacerbation is coded to 491.21

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• Chronic obstructive bronchitis with pneumonia
  Coding Clinic, Third Quarter 1997
• Assign codes 486, Pneumonia, organism
  unspecified and 491.20, Obstructive chronic
  bronchitis without mention of acute exacerbation.
  when a patient is treated for pneumonia and
  COPD. Pneumonia is not considered an
  exacerbation of COPD. These two conditions, when
  they occur together, will always be coded
  separately.

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• COPD with exacerbation Coding Clinic Third
  Quarter 2002 Page 19
• Use code 491.21 for COPD with exacerbation
• according to the code book acute is a
  non-essential modifier for 491.2X
• Decompensated COPD Coding Clinic Third
  Quarter 2002 pade 19
• Assign code 491.21, obstructive chronic
  bronchitis with acute exacerbation for
  decompensated COPD.
• decompensation exacerbation

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Clinical Example 1

• 72 year old man is admitted to the hospital due
  to complaints of severe dyspnea and increased
  sputum production. Testing reveals pulmonary
  infiltrates and decreased O2 levels. He is
  treated with IV antibiotics and respiratory
  therapy.
• The physicians diagnostic statement indicates
  Pneumonia and COPD.
• Principal diagnosis 486
• Secondary diagnosis - 496

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Clinical Example 2

• A 58 year old woman is admitted to the hospital
  with a diagnosis of COPD with exacerbation. The
  physician order testing which rules out
  pneumonia and orders respiratory therapy and IV
  antibiotics to treat acute bronchitis. The
  physicians final diagnostic statement indicates
  COPD with acute exacerbation and acute
  bronchitis.
• Principal diagnosis 491.22 COPD with acute
  bronchitis.

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Clinical example 3

• 45 year old woman presents to the ER complaining
  of an asthma attack. Her symptoms of dyspnea
  and wheezing are unable to be controlled in the
  ER and she admitted as an inpatient. The ER
  physician documents asthma and history of COPD
• The patient does not respond well to standard
  care and it takes several day for the asthma to
  come under control.

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Clinical example 3 (continued)

• The attending physicians documentation in the
  medical record indicates asthma w/ status
  asthmaticus and COPD.
• Principal diagnosis is 493.21 Chronic
  obstructive asthma with status asthmaticus

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References

• IPRO
• www.ipro.org
• ICD-9-CM Official Coding Guidelines
• www.cdc.gov/nchs/data/icd9/icdguide.pdf
• Tabular Addenda October 1, 2004
• www.cdc.gov/nchs/data/icd9/icdtab_addenda05.pdf
• Coding Clinic, AHA
• American Stroke Association
• American Lung Association
• Cornell University

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Questions and AnswersSubsequent to this
presentation, additional questions regarding
information presented here may be posted to
http//jeny.ipro.org under the Medicare Payment
Error Case Review Initiatives Breakout Room.