Know the risk, evaluate your exposure.
The FY 2019 Inpatient Prospective Payment System (IPPS), which includes the Medicare Severity Diagnosis Related Groups (MS-DRGs), went into effect Oct. 1, 2018. There is one area that did not get much attention regarding the changes that were included in this year’s update: spinal fusions.
During the Coordination and Maintenance Committee meeting held in September 2017, the topic of invalid spinal fusion codes was raised. There were spinal fusion codes, which included the character “Z” for no device. According to the ICD-10-PCS Official Coding and Reporting Guidelines, B3.10a-B3.10c, spinal fusions, require a device. In response to this observation, 87 ICD-10-PCS codes were deleted because they contained the no-device character. These codes did not meet the ICD-10-PCS definitions.
The next step in exploring this topic is understanding why this issue does not stop with the code deletions. If there was no device, then spinal fusion was not the correct procedure. What procedure codes should have been used to code these cases? When spinal fusion is assigned, the most frequent MS-DRG is 460, with a relative weight (RW) of 4.0375. If the procedure was actually a release of the spinal cord, then the MS-DRG would be 520, with a relative weight 1.3141. If the procedure was a reposition of the spinal cord or insertion of internal fixation device without reposition, then the MS-DRG is 517, with a relative weight of 1.3809. The relative weights do not sound impactful, but when converted to dollars, the impact is astounding.
The average payment for spinal fusion (MS-DRG 460) is $28,882.77, with the average Medicare payment $24,458.68. According to the National Summary of Inpatient Charge Data by Medicare Severity Diagnosis Related Groups for FY 16, the frequency was 79,495. The total Medicare payment for this MS-DRG is $1,944,342,766.60. Compare this to the average payment for MS-DRG 520, which is $9,208.77, with the average Medicare payment $6,944.51. If 10 percent of these cases were incorrectly assigned, then there would be a payback of $139,160,426.84, which is a significant chunk of change. This number is arrived at by taking 10 percent of 79,495, which is 7,945.50, and multiplying it by the difference between $24,458.88 and $6,944.51.
It is important to understand this risk and evaluate your exposure.
The first step to identifying your risk is identifying if you have submitted on a claim any of the ICD-10-PCS codes that included no device. You might want to narrow your population by reviewing all claims in the spinal fusion MS-DRGs (453-460, 471-473).
The second step is to complete a second review of these cases to determine what the correct ICD-10-PCS code would be for each identified case.
The third step is to understand your level of exposure. Identify the total number of cases as well as the MS-DRG shift. When you complete that analysis, it is time to contact the compliance officer to determine the best course of action for your facility. In my opinion, it is best to be proactive regarding identified issues.
In summary, determine if you are at risk regarding this latest change to ICD-10-PCS. Educate your coders regarding the correct code assignment for spinal fusion cases — not every documented spinal fusion is actually a spinal fusion, in ICD-10-PCS World.
Be proactive with any findings by involving the compliance officer. Spinal fusion could be the next big target for the Recovery Auditors and payers!
Program Note
Register to attend Laurie Johnson’s webcast on spinal fusion coding today at 1:30 p.m. ET.
At this point we probably shouldn’t be surprised by the Roberts Supreme Court’s willingness to eviscerate precedent in the name of strict textualism. On the
Last week I discussed the new-to-me terminology of “the patient-directed discharge.” Well, this week my new term is “administrative harm,” which was highlighted in an
Please log in to your account to comment on this article.
ICD10monitor has teamed up with renowned CDI expert Dr. Erica Remer to bring you an exclusive webcast on how to recognize sepsis, how to get providers to give documentation that will support sepsis, and how to educate to avert sepsis denials. Register now and become a crucial piece of the solution to standardizing sepsis clinical practice, documentation, and coding at your facility.
Optimize your inpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. Participants will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P., as she helps you navigate advanced inpatient CDI technologies, regulatory changes, and system interoperability. Angela will provide actionable strategies for integrating AI and predictive analytics into CDI practices, ensuring seamless system interoperability, and maintaining compliance with evolving regulations. Attendees will learn to select and implement advanced EHR systems and CDI software, leverage data analytics to enhance documentation accuracy, and stay audit-ready with the latest compliance updates. Real-world case studies and practical tools will empower you to drive continuous improvement in CDI, improve patient outcomes, and enhance organizational efficiency. Don’t miss this opportunity to advance your CDI practices and stay ahead in this dynamic field.
Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P, for an insightful webcast on improving inpatient clinical documentation integrity (CDI). Inaccurate documentation can lead to misdiagnosis, improper treatment, and compromised patient safety. High workloads, lack of standardized practices, and outdated EHR systems contribute to these issues, affecting care quality and financial outcomes. Angela will offer practical strategies and tools to enhance accuracy, consistency, and timeliness in documentation. Attendees will learn to use standardized templates, checklists, and advanced EHR systems, while staying compliant with regulations. Improve patient care, ensure accurate billing, and reduce audit risks with actionable insights from this essential webcast.
This webcast, presented by Tiffany Ferguson, LMSW, CMAC, ACM, addresses the critical gap in Social Determinants of Health (SDoH) reporting for pediatric populations. While SDoH efforts often focus on adults, this session emphasizes the unique needs of children. Attendees will gain insights into the current state of SDoH, new pediatric Z-codes, and the importance of interdisciplinary collaboration. By understanding and applying pediatric-specific SDoH factors, healthcare professionals can improve data capture, compliance, and care outcomes. This webcast is essential for those looking to enhance their approach to pediatric SDoH reporting and coding.
Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, VP of CDM, for a webcast addressing oncology service coding challenges. Learn to navigate coding for infusions and injections alongside Evaluation and Management (E/M) services, ensuring compliance and accurate reimbursement. Gain insights into documenting E/M services for oncology patients and determining medical necessity. This webcast is essential to optimize coding practices, maintain compliance, and maximize revenue in oncology care.
During this webcast Dr. Ronald Hirsch delves into the inpatient admission order process including when to get it, when it becomes effective, its impact on billing and payment, who can write it, how to cancel it, the effects on the beneficiary, and more. You’ll leave with a clear understanding of inpatient orders and guidelines for handling improper orders that you can implement immediately.
Michelle Wieczorek explores challenges, strategies, and best practices to AI implementation and ongoing monitoring in the middle revenue cycle through real-world use cases. She addresses critical issues such as the validation of AI algorithms, the importance of human validation in machine learning, and the delineation of responsibilities between buyers and vendors.
Copyright © 2024 RACmonitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
