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ICD-10 Intelligence

Pre-Bill Audits Get Granular

Which MS-DRGs are the best targets and how to proceed.

Q: We are moving ahead with pre-bill audits. Now we are in the process of determining which MS-DRGs are the best targets. Which do you recommend and are there any other ways to narrow our focus?

Congratulations on starting pre-bill audits. Now it's time to pinpoint specific MS-DRGs for review. Plan your pre-bill audit process carefully. A successful pre-bill audit program for inpatient claims should include the following:

•    High-risk MS-DRGs
•    Present on admission (POA) indicators
•    Severity of illness
•    Risk of mortality
•    Clinical indicators
•    Discharge dispositions
•    Unspecified codes

The primary question is how to identify high-risk MS-DRGS. High-risk MS-DRGs typically fall into one or more of the following eight categories:

1. High-dollar MS-DRGs. Third-party auditors monitor high-dollar claims regularly. It's important to closely scrutinize the assigned ICD-10-PCS codes as part of your audits. An incorrect body part, for example, could generate an incorrect PCS code that could, in turn, generate an incorrect MS-DRG. At HRS, we've seen this happen frequently with incorrect PCS codes that incorrectly drive the case to MS-DRG 983 (extensive operating room procedure unrelated to the principal diagnosis without CC/MCC).

2. MS-DRGs with only one CC or MCC. Be sure documentation supports the assignment of that single CC or MCC.  These cases are also often flagged for review by third-party payers to assess whether the CC/MCC is sufficiently documented or can be removed to significantly reduce the MS-DRG payment to the organization.

3. MS-DRGs with no CC/MCC. Does the length of stay make sense, given the original coding that indicates a lack of comorbid conditions or complications? If the patient stayed longer than a few days, it likely means there were other factors compounding the care required that may have been missed by the coder.

4. Long stay, low-weighted MS-DRGs. Are clinical indicators present for diagnoses that aren't documented at all or not documented consistently?  It may be necessary to query the physician to obtain clarification or additional documentation to support the patient's condition or care rendered.

5. Short stay, high-weighted MS-DRGs. Does documentation clearly support the CCs and MCCs? Did the case involve a transfer to a higher level of care? Was it a mortality?

6. Coding/CDI mismatch. Why do coders and CDI specialists disagree? Is it a coding error? Did CDI specialists miss a concurrent query opportunity?

7. Mortality cases. Is the record complete, and does it reflect a high severity of illness and risk of mortality? Are CCs and MCCs documented and coded appropriately?

8. Diagnoses or procedures on the OIG/RAC hit list. We suggest honing in on the following: mechanical ventilation (5A1955Z) and kwashiorkor (E40), which is a very specific type of protein deficiency that was being erroneously assigned within certain encoder pathways.  
Conducting the pre-bill review: 3 steps

Once you've identified your target MS-DRGs, take the following steps to conduct the review.

1. Place the bill on hold. Then move the chart to an audit queue.

2. Conduct the audit. Confirm the presence of appropriate clinical documentation, assess the quality and content of the clinical documentation to support the assigned codes, and evaluate the assigned codes versus the application of final codes. Be sure to use updated coding books, coding guidelines, Coding Clinic references, and clinical indicators when conducting the audit. For example, when auditing malnutrition cases, use updated criteria from the American Society for Parenteral and Enteral Nutrition (ASPEN).

3. Analyze the audit results. If the audit reveals no findings, send the claim to billing for submission. If the auditor disagrees with the MS-DRG, initiate a dialogue between coding, CDI, and/or a physician champion. Determine who will perform any necessary queries, finalize the chart, and perform education as needed.

Delivering Results

Pre-bill audits are your organization's best defense against claims denials and payer recoupment audits. They are also a clear preemptive effort to maintain financial accuracy and sustainable revenue through a proactive approach. By ensuring clean claims from the onset through pre-bill audits, your healthcare organization not only mitigates risk, but also enhances revenue accuracy and reduces cost.

Kimberly Carr is director, clinical documentation, and Jonathan LaFleur, is an auditor, both at HRS.

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