Vol. 14 Issue 18
Coding in the Long-term Acute Care Setting
Have the Rules Changed?
In January 2001, I had the pleasure of writing an article titled "Coding in the Long-Term Acute Care Setting" for ADVANCE (Jan. 29, 2001). At that time, rules for prospective payment system (PPS) reimbursement for long-term acute care hospitals (LTCH) were in development, and coders used the coding guidelines established for patients admitted to the short-term acute care hospital (STCH).
After the article was published, I received many positive responses and fielded quite a number of questions regarding coding in this environment. I eagerly awaited the LTCH PPS regulations.
The final LTCH PPS regulations were published in 2002 and became effective beginning with cost reporting periods that began on or after Oct. 1, 2002. The good news was, with very few additions, the long-term care DRGs (LTC-DRGs) remained the same as those assigned to the STCH. However, and most importantly, the weights were different. The changes in weights seemed in many cases to question the core of which patients were "right" for admission to the LTCH. In certain cases, changes in weights seemed to have sweeping impact on which types of patients may be affordable for admission to an LTCH. So, it seemed the appropriate time to write "Coding in the LTCH Setting, Part 2."
A Look at Resources: Then and Now
In early 2001 when my first article was published, there were no LTCH specific resources to assist in coding. For admission to an LTCH, patients had to meet acute care criteria, so coders used American Hospital Association (AHA) guidelines for coding in the inpatient setting, which were developed for use in the STCH. LTCHs used DRG assignments, relative weights and computed case mix figures from STCH groupers to assess patient acuity, severity of illness and the services provided.
•LTCH Final Rules: Once the final rules were published in 2002, coders had the Centers for Medicare and Medicaid Services (CMS) LTCH rules to use as a resource (www.cms.hhs.gov/providers/longterm). The most recent update was published in June 2004. Training materials, including LTCH PPS Clinical Issues, # 3, Coverage, Coding and Medical Review, can also be found there.
When using the LTCH weights, careful evaluation of patients must occur. High weighted medical DRGs in the STCH included such things as pulmonary em-bolism, sepsis and bacterial endocarditis. Patients with those diagnoses had been commonly treated in the LTCH setting prior to PPS. However, what was once a high weighted DRG while using the short term weights may now carry a significantly lower weight in the LTCH classification system. For example, a patient treated with the principal diagnosis of bacterial endocarditis, DRG 126, in the STCH carries a weight of 2.5418. In the LTCH environment, the weight of that DRG is 0.8706. Another example is digestive malignancy, DRG 172. In the STCH, the weight is 1.3670. In the LTCH, the weight is 0.8702.
The reverse of that happens in the following DRG example. A patient with principal diagnosis of hypertension, DRG 134, has a weight of 0.9154 in the LTCH setting. That same DRG in the STCH is weighted 0.5954.
Another example to review is urinary tract infection with candidiasis in the male and female. In the LTCH, the male is grouped to DRG 350, with a weight of 1.1820. The female is grouped to DRG 368, with a weight of 0.6963.
Finally, expansion of the V codes, added in October 2002, seem to capture the reason for admission to the LTCH on a number of patients. These codes are V54.19, V54.13 and V58.89. Patients with these code assignments fall into the aftercare of surgery, medical conditions and fractures DRGs: 465, 466 and 249. DRGs 465 and 466 cover those patients admitted without an acute complication from surgery or acute medical condition(s) but need hospitalization due to complex medical/surgical history. DRG 249 covers patients who need LTCH hospitalization following the acute phase of fracture(s). Coding to these DRGs are preferable to coding DRG 462 Admission for Rehabilitation. This is true even when patients are receiving rehabilitation that is commonly provided as part of the services in the LTCH setting.
•Coding Clinic: A second important resource is now Coding Clinic. Most recently, the AHA published LTCH Coding guidelines in Coding Clinic (4th Quarter 2003, pp. 102-112, Coding and Reporting for Long Term Care Hospital).
I was very pleased to see that LTCH coding was finally addressed, and it is my strong belief that a future Coding Clinic will offer a clarification to the usage of V57.89, Admit for Rehabilitation; and, it is my hope that other LTCH scenarios and coding questions will be addressed in future issues also.
•.Coding Seminars: A third resource needed is to attend an LTCH coding seminar. Virtually non-existent a few years ago, seminars are now being routinely offered. There were several held in the past year in my area of the country alone. I would especially encourage those new to LTCH coding to research the availability of LTCH coding seminars and make sure they are in attendance.
Yes, the Rules Have Changed
In summary, I would like to leave each of you with this in mind. Yes, the rules have changed, quite simply because LTCH specific rules now exist.
Overall coding guidelines have not changed, and in fact the official (STCH) coding guidelines were printed as part of the final LTCH rules in 2002. The recent publication of LTCH coding guidelines in Coding Clinic and the availability of Clinical Issues at the CMS Web site have helped to clarify LTCH specific scenarios and coding questions. Presently, coders are much better equipped to properly code in this health care setting. The future of LTCH coding can only look brighter. So, I leave you once again with these words: happy coding!
Carmen Blakeman is director, HIM/MSS, HIPAA Privacy Officer, LifeCare Hospitals of New Orleans. She can be reached at firstname.lastname@example.org.