Today's podcast is going to focus on a few
of the applications
that you would see if you were
coding in an inpatient environment- the
Encoder. Computer-Assisted Coding and the
the DRG Grouper, which is inside the Encoder usually.
They are all used together when a
coder is coding a chart. I can't show you
these applications because I don't have
access to them so what I've tried to do
is explain to you what each application
would do and if you're lucky enough to
get into a practicum environment where
you can actually see this software, the
words will not be foreign to you. You
will know what's supposed to happen and
how these things work together. The
Encoder is an application that includes
all the code sets, ICD-10-CM, ICD-10-PCS, CPT
and HCPCS, all the Medicare edits, all the
commercial payer edits, Medicaid edits.
Those are the "rules" that
each one of those insurance companies
have that pretty much makes
sense to have. I think, for example, there's a
"gender" edit where it's checking to make
sure that the claim that's being presented
doesn't have a male having a
hysterectomy, for example, or a female
having a prostate operation. Edits can
follow gender, age, national and local
coverage determinations, all kinds of
rules around them. The claims that go
into these edits, if they come through
everything, it's called a "clean claim"
meaning that it hasn't hit any edits and
it's gone through everything and can now
be processed to assign the DRG. So all of
that to explain what edits are. The
Encoder also has the Coding Clinic (publication) that
we've introduced earlier in the semester,
and the CPT Assistant which is a similar
publication but focusing on the CPT (code set).
There's medical dictionaries, there's the
Physician Desk Reference and many more
reference publications. All of those
things leading to helping the coder
assign the code. This link i have here
was also
given to you another place in the course.
That's just a video demonstration of the
Encoder that gives you some idea of its
functionality. Computer-Assisted Coding, I
have two slides here for this. This is
software that uses algorithms and
natural language processing to figure
out what terms or words in documents
might need a code, a medical code. The
software analyzes the healthcare
documents and produces codes for these
phrases or these terms. The CAC
automatically generates suggested codes
and then the coder comes along and
focuses on the review and the validation
of the output from the CAC. That
leaves the coder free to do a lot of
other things, other than just selecting a
code. That's the rationale anyway.
There's a lot of benefits to
using a Computer-Assisted Coding. AHIMA
does recommend it and a lot of our
hospitals are using it. One thing that
Computer Assisted Coding does
particularly well is identify
secondary diagnosis because it may be
mentioned in only one place in the
chart and the coder may miss it but the
CAC is going to catch it. Because the
CAC technology can identify those CCs
and MCCs which will be going over in a
few minutes, facilities found them very
helpful in improving their case mix.
What that means is getting the most
reimbursement by accurately
capturing all the codes they can capture
for a patient. An example that was given
in one of my texts, University of
Pittsburgh Medical Center found 22
million dollar increase in revenue by
using Computer-Assisted Coding to
capture those morbidities and
comorbidities. The grouper then, we've talked
about the Encoder. Computer-Assisted
Coding and the Grouper, the Grouper is a
calculation. It takes all this
information. We're going to be talking
about the "elements" that it looks at in a
second. But it's going to be taking the
principal (diagnosis), the secondary diagnoses, the
surgical procedures, the gender, the sex
of the patient and the discharge status.
All of these elements impact payment.
One point I want to make about the
secondary diagnoses- you can't
just randomly select diagnoses. You have
to select those that are dictated by the
UHDDS guidelines. Severity of condition is
another thing I want to talk about here.
In the code book, there's a little text
box to the right of some of the codes
that says "MCC" which means "major
complications or comorbidities" or "CC"
which is "complications or comorbidities".
Those codes that have those indicators
can impact a DRG assignment. In other
words, it will impact it to be a more
expensive case if the patient presents
with diagnoses that include an MCC or CC.
Now, for example, these DRGs we are
looking at, the DRG 190 is for COPD
with an MCC. On the next slide, I am going to give
you some examples of these. DRG191 is
COPD with CC and DRG 192 is
COPD without any CC or MCC. So here's
some examples. J44.9 is your COPD
diagnosis. If a patient also has I22.1
which is a subsequent ST elevation or a
myocardial infarct of the inferior wall,
that is an MCC, when a patient has
both the COPD and this MI of the
inferior wall. Those two things would
assign this patient to DRG 190. In the
next example, if a patient has COPD and
phlebitis of the right popliteal vein
that is a CC and that would throw the
patient into DRG 191. Then if the patient has
neither a CC nor an MCC, they
would be assigned to the DRG 192. By
having the little text there at the bottom of
this slide, Appendix E in your code book
lists the MCC codes for the code book
2017
Appendix F lists the CC codes for 2017.
I'm going to try and walk you through
how this would work and it's really an
oversimplification but it, at least,
allows you to mentally
process how this would have worked in
the work environment in the inpatient
hospital. The coder would open the
medical record on the screen and would
choose specific commands that will show
both the Encoder and the
Computer-Assisted Coding software
results. You would see them side-by-side.
Those two systems interface meaning
the CAC would identify a diagnosis and
then use the coding software and Encoder
to assign that code or they may have
other software that does the same thing.
The idea is you have these two software
systems working side by side. Then
several documents would be reviewed for
diagnosis and procedures. They would
include an H&P, operative reports,
consultations, any diagnostic tests, those
types of things. The CAC would
highlight the diagnosis or the
procedures which should be coded and
assign a code. You're going to see an example
a little bit later in this presentation
where I've got an H&P and you're
going to see where the CAC captures
diagnoses that were not captured the
first time. Then they're going to be
added to your (list of) diagnoses. The coder is
going to look at the Encoder and is
going to decide whether the
coder wants to add or delete those codes
that the CAC has selected for code
assignment. Following
everything that's been assigned, the DRG
Grouper is then going to assign the DRG
for the hospital stay. It's really an
MS-DRG. The government changed the name of
it but you will often hear those two
terms used interchangeably, with the
correct thing to say is the
MS-DRG. I should have put that
everywhere where I say DRG; I
should really be saying MS-DRG.
So then the elements again,
what we're looking for that the grouper is
going to assign- the principal (diagnosis), the
secondary diagnosis, principal procedure,
the discharge date, age, the gender, and
the discharge status.Why are these
things important? The principal diagnosis
is going to be the first thing that's
considered and the most heavily weighted for
which major diagnostic group these
things go into. Your secondary
diagnoses are chosen based upon the UHDDS
guidelines. The principal procedure
is also a major player in the assignment
of the DRG. There are categories of MS-DRGs
that are driven by the principal
procedure instead of the principal
diagnosis. I don't want to over
complicate this but for now, just
remember that those are extremely
important.The discharge data is
important because of the length of stay, how
long the patient is in the hospital is
significant in its measurement and the
way it goes into the formula. The age of
the patient is monitored. The gender, I
mentioned some of those edits that we
talked about earlier. There are also "age" edits. For
example, a child would not be having a
mastectomy if there's no breast (developed). That's a
just an example. Discharge status has to do
with where's the patient go after
discharge. If the patient goes home,
there's one payment. If the patient goes
to a skilled nursing facility or another
hospital, there's other payments. There's also
many things that are considered that I'm
not going to go into in this final
calculation of how much money the
hospital gets. It's very complicated and
it was covered in HIT105 (Principles of Reimbursement). You may want
to go back into the HIT105 textbook
Principles of Healthcare Reimbursement
and look at that again. I don't want to
spend the time on it at this time. What I
want to focus on now is that you
understand the Encoder, CAC and the
DRG Grouper and how those all work together to
assign the DRG. So how do we get to that
payment amount? Okay the hospital
calculates the MS-DRG
so
there's an estimate of payment that will
be received. That is just the hospital's
estimate (of reimbursement). The bill then goes from
the hospital (the claim) from the hospital to
the Medicare Administrative Contractor
or the MAC. In this case, I'm talking
about every Medicare patient that is
being treated but really it's any payer.
The same process is going to be followed.
I'm using Medicare here as my example. The
information is then entered into the
Medicare Code Editor, which I mentioned
to you earlier, to sort out cases that
need further review before assigning
the MS-DRG and based on that information,
all those elements, the MAC then categorizes
the case into the MS-DRG. That MS-DRG is
then calculated using software that
takes into account these many factors
that I wasn't going to go into. Words
like "disproportionate share" or "critical
access hospitals" may mean things to
you. Those are just some of the things that
might affect the calculation. I have
also that the MS-DRG payment can be
reduced, for example, when the patient's
discharged to a post acute setting, as
is the case in the example that we're
using in today's lecture. This is a
disclaimer. I want to say that what we're
looking at today the H&P I wrote myself.
The patient, Roger Campbell, is a fictitious
name. The medical record number is also
fictitious. The operative
report is taken from a case study in
Lynne Kuehn's book published in 2017. The
abbreviation right TKR stands for right
total knee replacement. That's the
surgery that we're going to be having for
our patient (example). Now, here's a screenshot of
the H&P but you also will find in this
module (in D2L), you're going to find the H&P
that I have created and you can see
where I highlight in the green font
those things that are significant. He's 75,
it's a right knee.
He has severe right knee (pain).
He had a left knee arthroplasty in 2009. He has
right knee osteoarthritis or OA. His
secondary diagnoses include
hypothyroidism, neuropathy, history of
major depression with psychotic symptoms
which has been recurrent. Then I have (the list)
of meds.
Past surgeries and
hospitalizations- I have there the left
knee replacement in 2009, all those
admissions to the psych unit. Then
you see what the coder didn't pick up,
I'm trying to show here what the coder didn't
pick up and what the CAC did catch is
that the list of diagnoses that the
coder used at the end of this document
did not capture a few things that are
captured here in the comments. Multiple
diverticuli on the colonoscopy last October,
adding a diagnosis of diverticulosis.
That is not listed at the end of the
H&P. A little bit later, I have on
here this known right knee OA is (listed) but
not the right shoulder and not the
bilateral hips, so those diagnoses of
osteoarthritis also need to be added.
This is an attachment that you can
download and read because you need to
get used to reading a document to
understand what you search for when
you're choosing your codes. So we keep
going down and here you see I have the
admission diagnoses and it does not
include those things that were captured
by the CAC, those secondary diagnosis up
at the top where I have it as "comments"
This would be the
Computer-Assisted Coding capturing these
phrases or words that the coder missed
on the first review. This would be an
example of those places where the coder
does the first flush (or review), if you will and
then the CAC does the second. Other times, CAC does the entire thing and the
coder's just reviewing codes. It really
just depends on how this is being used
at the different hospitals.
So this is just a screenshot of what I
just showed you with the highlights of
the diagnoses. There's some more. There's those
2 comments with those diagnoses
that were not mentioned at the end of
the document.What this is telling us is
don't make the mistake of just going to the
end of a document (to look for diagnoses). You really have to
read the entire record to do it. So now
I've taken these diagnoses that were
in the H&P and I'm showing you before
the computer-assisted report was
reviewed. This would have been the
diagnosis. Up until the principal
procedure, those are all ICD-10-CM
diagnosis. Then you see I had
mentioned his age, his gender, his
discharge status. In this case, this
patient is going to go to skilled nursing
facility. Now I have added those
diagnoses that were not captured before
the final review by the CAC and I've
added them here. What i want you to see
though is that even though we've
captured them, they do not have an MCC or
a CC so they really are not going to
impact the DRG assignment when you've
got everything (coded). It's just a more thorough
job of coding when you've got everything
captured that should be captured for
that patient. You also notice the
major depression with psychotic symptoms, recurrent.
It does have a CC but not an
MCC. We will talk about that in a minute. The last
column on the right, the Present
on Admission indicators. As you see, the
patient had all those things when he was
admitted and I double-checked with a
veteran coder to be sure i was telling
you this correctly. Even though the
patient denies any current depression,
when he carries a diagnosis with
recurrent symptoms like major depression
with psychotic symptoms recurrent, that
would be "present on admission" . It's
like someone with asthma not having
asthma
attack when they're admitted to the
hospital. They still have asthma. So that
would be the case with this patient. He
has that history, it is a very strong
history. It happens recurrently, so it
would have a POA of "yes". Now, I will look
at the operative report. This is taken
from Lynn Kuehn's book and what I've done
here in the operative report is I've
highlighted those things that are going
to help me assign the PCS code. This
is not a PCS course. I am just introducing
the topic so when you get to HIT231. this
will not be completely new to you. The
procedure is a right total knee replacement
and is using cement. That is significant.
This implant it's using is a "synthetic
substitute". It is a "total" knee; you know
that because you have three components-
the femoral component, a tibial component
and the patellar component. The three
things make it a "total" (versus a partial) knee replacement.
If one or two of these were being
replaced, it would be a "partial" knee
replacement. The cement is mentioned
several times. Here a "straight anterior
skin incision" tells you that it was an
"open" procedure. Osteotomy and cutting
of the bone, a patellar osteotomy. This
helps me know the root operation is a
"replacement" because you're going to
actually physically cut out the joint
that exists and replace it with a
synthetic substitute. That's what a joint
replacement is, it's a replacement
operation. Then I talked about
another polyethylene, that's a synthetic
substitute. All those things I just
highlighted help me assign a code. I
have here the seven characters that are
part of a PCS code and each character
has a meaning. The "0" (zero) here refers to the medical
surgical section. The body system is a
lower joint which
is an "S". The root operation is
"replacement" which is an "R". The body
part is a right knee joint that's a "C".
The approach is open that's "O" (the letter "O". The synthetic
substitute is represented by "J" and the
"cemented" which is a qualifier is "9".
I don't want to get any deeper than that. I just wanted you to
see an operative report looked like and
how you would be looking for various
things to help you be able to assign
those 7 characters (for the PCS code). These are just
screenshots, so the very same thing we
just looked at on my desktop where I've
highlighted certain things. Then we
get to the assignment of the PCS code.
The discharge status, you may remember
from HIT105, Medicare rules dictate how
reimbursement is distributed and most
insurers follow Medicare's rules. If the
patient does not go home, the total
amount paid by Medicare or the insurer
is divided between the hospital and
whoever the receiving facility is. In
this case, our patient is going to
skilled nursing so that does impact the
DRG payment. All this information on Mr.
Campbell would be entered into the
Encoder's DRG grouper and joint
replacement surgery is a major
diagnostic category. Joint placement is
differentiated by either "with MCC" or
"without MCC". This patient Mr. Campbell
had no MCC so MS-DRG 470 would be
assigned. He did have a diagnosis with
major depression with psychotic symptoms (F33.3)
but it had only a "CC", not an "MCC"
so the CC would have no impact on the
assignment at a DRG. I know this is a lot
that I've thrown at you but I wanted you
to at least understand how these things
work together. If you have any questions, let me
know. I'll do my best to answer them and
I hope you will watch this more than
once to really have these terms and the
functionality in your mind so that going
forward you know that these things have
to work together in order for an MS-DRG
to be assigned.
That is the basis of how the
hospital gets paid. MS-DRG is part of the
inpatient prospective payment system (IPPS).
I know you probably remember that from HIT105.
There are many prospective payment
systems for any healthcare setting.
Skilled nursing has a PPS; Inpatient
Rehab has a PPS; Home Health has a PPS.
They're all different. They all have
different rules. What I've shown you
today is the Inpatient, how Inpatient PPS
works as far as the DRG assignment. Thank
you so much and have a good day.