Last August, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) reported its findings on a review of certain MS-DRGs that required more than 96 consecutive hours of mechanical ventilation.
A total of 250 claims were sampled, and on 233 of those, the Medicare payments complied with the requirements. That left only 17 where those payments did not comply. For eight of those claims, the incorrect PCS code was assigned; the code for more than 96 hours of ventilation was assigned when the patient did not receive that degree of mechanical ventilation.
For the other nine sampled claims, the incorrect diagnosis code was assigned, or a procedure code was assigned that was not related to mechanical ventilation. For the 17 sampled claims where MS-DRG 207 or 870 was assigned incorrectly, it was determined that $382,032 in overpayments resulted.
The OIG then estimated, based on this sample result, that improper Medicare payments of $79.4 million were paid during the audit period. The report notes that the hospitals confirmed they used the incorrect CM or PCS codes, with incorrect counting of the hours of ventilation received being a factor.
With the current emphasis on monitoring for improper payments, it seems like a good time to review mechanical ventilation coding issues. Our code options note duration options of less than 24 consecutive hours, which is reported with 5A1935Z; respiratory ventilation, 24-96 consecutive hours, reported with 5A1945Z; and then respiratory ventilation, greater than 96 consecutive hours, reported with 5A1955Z.
The Coding Clinic from the fourth quarter of 2014 is a good review. Guidance notes to start counting the duration of mechanical ventilation at either the time of endotracheal intubation (and subsequent initiation of mechanical ventilation) or initiation of mechanical ventilation through a tracheostomy – or at the time of admission, in the case of a patient who was previously intubated or has a tracheostomy and is on mechanical ventilation. For those patients who ultimately receive a tracheostomy following ventilation via endotracheal intubation, the time starts at the beginning of the intubation.
Coders often get confused on how to time the weaning process from the ventilator – at what point do we stop counting the time? We would include the entire weaning process as time counted toward the correct code assignment. The stop time would be when the patient is extubated, and the mechanical ventilation turned off. This should be clearly documented in the medical record. Make sure coders know where to find this information – it’s not always easy with some electronic health records (EHRs).
This is a good review topic for your coding team. A focused audit of how coders are assigning mechanical ventilation might be a beneficial exercise.
To ensure consistency and communication between coders on the team, set up a lunch-and-learn session or group chat on how they count ventilation time, making sure everyone is refreshed on the Official Coding Guidelines and applying them consistently.
This clears up confusion and helps build a great coding team.
Programming note: Listen live today for the Coding Report with Chris Geiger when she joins the Talk Ten Tuesday broadcast at 10 Eastern with Chuck Buck and Angela Comfort.
Let’s start with what seems to be a never-ending topic of conversation: the new policies by Medicare Advantage (MA) plans to deny or reduce payments
Hotly anticipated performance targets and payment amounts for the Centers for Medicare & Medicaid Services (CMS) Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model
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