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A hospital recovery audit contractor (RAC) coordinator discovered that, over a six-month period, the Medicare RAC denied a significant number of cases in which “aspiration” was inappropriately coded as aspiration pneumo­nia (ICD-9-CM code 507.0—pneumonitis due to inhalation of food or vomitus).

The hospital’s use of RAC audit software was instrumental in the RAC coordinator’s ability to identify this pattern. In fact, the RAC denials for these cases resulted in MS-DRG reassignments with reimbursements lower than those originally received by the hospital.

Hospital staff took the following actions.

  • The RAC coordinator informed the compliance officer and the health information management (HIM) director of this adverse coding pattern.
  • A decision was made to generate a report that listed all of the inpatient discharges for the past 18 months that contained a principal or secondary diagnosis code of 507.0. This was a multi-payer report.
  • One of the hospital’s compliance auditors reviewed all 118 of the inpatient cases that contained code 507.0.
  • The compliance auditor identified 46 multi-payer inpatient cases in which “aspiration” was inappropriately coded as aspiration pneumonia. These cases were coded by all of the coding specialists.

A multi-faceted corrective action plan was imple­mented that included the following steps.

  • Coder training would be conducted by the coding manager. It would include a thorough review of the official aspiration pneumonia coding guidelines published in the American Hospital Association’s Coding Clinic for ICD- 9-CM First Quarter 2011, First Quarter 2008, Third Quarter 1991, and First Quarter 1989.
  • The clinical documentation improvement (CDI) specialist would conduct physician-doc­umentation training with a focus on aspiration pneumonia.
  • The 46 cases discovered to have problems would be rebilled, with collaboration among the patient financial services’ director, coding manager and compliance officer.
  • The hospital’s compliance auditor would perform a three-month internal pre-billing review of ALL inpatient cases reported with code 507.0.

Although no hospital wants to find that it has a history or pattern of coding and/or documenta­tion deficiencies, there is some comfort in know­ing that the RAC process is actually another tool by which a hospital can detect and respond to compliance violations.

About the Author

Susan Howe is a senior healthcare consultant, clinical consulting services, Panacea Healthcare Solutions, Inc., St. Paul, MN.

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