The document discusses an upcoming presentation on auditing respiratory neoplasm cases for RAC denials and focuses on understanding the RAC's concerns regarding these cases, incorporating clinical guidelines to aid in auditing practices, and reviewing key documentation elements and common issues seen in respiratory neoplasm cases to facilitate successful appeals.

1. Respiratory
Neoplasm
Charmira Orr BS,LPN,CCS,CPC,CCDS
Director of Coding and Appeals
Intersect Healthcare, Inc.
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2. Learning Objectives
Participants will review and understand
the RAC’s focus
Participants will review and understand
how to incorporate g
p guidelines to aid in
auditing practices
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3. The RAC’s Focus
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4. Diagnostic
Information
Procedures
Discharge
Diagnosis
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5. MS‐DRG 180,181,182
Issue Details Name Respiratory 175, 176, 180, 181, 182, 183, 184, 185, 186, 187, 188, 192, 196,
197, 198, 199, 200, 201, 202, 203, 204, 205, 206 (Medical Necessity Excluded) Number
B001232010 Description MS-DRG validation requires that diagnostic and procedural information
and the discharge status of the beneficiary, as coded on the hospital claim, matches both the
attending physician description and the information contained in the medical record. Reviewers
will validate MS-DRGs 175, 176, 180, 181, 182, 183, 184, 185, 186, 187, 188, 192, 196, 197,
198, 199, 200, 201, 202, 203, 204, 205 and 206 for diagnoses and procedures affecting the MS-
DRG assignment. Claim Type Inpatient Issue Type Complex Overpayment / Underpayment
Overpayment and Underpayment Dates of Service 10/1/2007 - Open States IL, IN, KY, MI, MN,
OH,
OH WI Policy Related Links ICD 9 CM Coding Manual (for dates of service on claim)
ICD-9-CM
ICD-9-CM Addendums and coding clinics
PIM Ch 6.5.3, Section A – C - DRG Validation Review
Present on Admission Indicator Systems Implementation
OIG - Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99)
Date Approved 6/10/2010
CGI Federal , 2010 ©
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6. Things We Know
Without CC/ CC
ih CC/MCC • GMLOS 3.0,
G OS 3 0 RW 0.8159
0 81 9
With CC • GMLOS 4.3, RW 1.2062
With MCC • GMLOS 5.9, RW 1.7263
Principle Diagnosis • Malignant, Secondary,
Benign, In situ, Lipoma’s
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7. Principle Diagnosis
• The condition found after study to have occasioned the
current admission or encounter
• The majority of treatment can often be used as a guide to
selecting the principal diagnosis
selecting the principal diagnosis
• Primary and Secondary Sites
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8. PRIMARY VS. SECONDARY
SEQUENCING GUIDELINES
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9. PRIMARY
When treatment is directed toward the primary site,
the malignancy of that site is designated as the
principal diagnosis unless the encounter or
hospital admission is solely for the purpose of
radiotherapy, chemotherapy, or immunotherapy
py, py, py
– Then the primary malignancy is a secondary
diagnosis, Encounter ( V-Codes ) First
– If two primary sites are present, each is coded
p y p ,
as a primary neoplasm
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10. Follow the Treatment
If there are 2 primary sites, however, treatment is
directed primarily toward one site, that site should
be designated as the principal diagnosis
If treatment is directed equally toward both sites,
either may be designated as the principal diagnosis
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11. Secondary Sites
If treatment is directed only at the secondary
site, the secondary site is designated as the
principal diagnosis
– An additional code is assigned for the primary
malignancy
– A V ‐ code is assigned as the additional code if the
primary site has resolved
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12. Presumed Secondary
Neoplasm
Mediastinum
di i
Meninges
Peritoneum
Pleura
Retroperitoneum
Spinal Cord
Sites Classifiable to 195
Bone
Brain
Diaphragm
Heart
Liver
Lymph nodes
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13. Secondary Diagnosis
Diagnoses that coexist at the time of admission or
develop subsequently or affect patient care for the current
hospital episode.
Should only be documented when?
Clinically
Evaluated
Increase
Diagnostically
nursing care or
Tested
monitoring
Therapeutically
Increased LOS
Treated 13
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14. Common CC/MCC Conditions
• Asthma w/acute
h / • Aspiration pneumonia
i i i
exacerbation or status • Empyema
asthmaticus • Pneumonia
• Bronchitis w/ acute • Pulmonary embolism
exacerbation
• Lung Abscess
• CKD
• Spontaneous tension
• Respiratory insufficiency pneumothorax
• Pulmonary edema • Mediastinitis
• Pneumothorax • Bacterial pleural effusion
• Tracheostomy • Acute Respiratory Failure
p y
complications
li ti
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15. Common Diagnostic Procedures
• CXR
• CT scans
• PET scans
• Sputum Cytology
• Biopsies
• Bronchoscopy
• py
Mediastinoscopy
• Bone scans
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16. Common Treatments
• Radiotherapy, Immunotherapy, or Ch
di h h Chemotherapy
h
• When a patient encounter is solely for the administration of
chemotherapy, immunotherapy, or radiation therapy, assign
the appropriate code as the first-listed or principal
diagnosis - ( V –Codes)
• If the encounter is to receive one or more of these
therapies, each pertinent code should be assigned, in any
sequence
• Additional code should be assigned for the malignancy
• Procedure codes should also be assigned
– 92 2x Radiation therapy
92.2x
– 99.28 Immunotherapy
– 99.25 Chemotherapy
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17. Documentation Highlights
• Acute vs. chronic
• Diagnostic test –documented diagnosis
• Diagnostic reports- document diagnosis in
progress notes
• I iti t d t
Initiated treatment or plans
t t l
• Severity of condition
• Etiology of condition
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18. Auditing for Neoplasm
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19. Worksheet
Length of stay:
h f
Discharge status:
Home or Self Care ‐01
Discharged/ Transferred to a Short Term General Hospital for Inpatient Care ‐
02
Discharged/ Transferred to a SNF with Medicare Certification in Anticipation
of killed Care ‐ 03
Discharged/Transferred to an Intermediate Care Facility ‐ 04
Discharged/Transferred to Another Type of Health Care Facility Not elsewhere
in the Code List‐ 05
Discharged/ Transferred to Home Care‐ 06
AMA ‐07
Expired‐20
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20. Worksheet
Admission Orders:
d i i Od
Malignant condition noted
Was treatment during stay directed at this area: Yes or No
Was patient admitted for treatment only? Yes or No
Were there any complications noted during stay? Yes or No If so, please
list_________________________________________________________________
list
_________
Were any procedures performed on either the primary or secondary malignancy?
Drop Down Box Yes or No If so; please list ‐‐‐‐‐‐‐‐‐‐ Then area to fill in the
blank______________________________________________________________
_______________
Is there any mention in the medical record that a primary malignancy has been
Is there any mention in the medical record that a primary malignancy has been
excised or eradicated? Box Yes or No if so; is there any treatment directed at this
area? Yes or No
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21. Worksheet
Is the primary malignancy still present, but treatment is directed at the secondary site
h i li ill b i di d h d i
only during the admission?
Secondary diagnosis:
___________________________________________________________________
__
Were these diagnoses treated during pt. stay? Yes or No if so; list Fill in the blank
treatments__________________________________________________________
__________
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22. Appealing a
Respiratory
Neoplasms
Inpatient Denial
‘Yomi Faparusi, MD JD PhD
Director, Medical Review and Research,
Intersect Healthcare, Inc.
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23. Learning Objectives
Understand how to create a successful
coding or medical necessity appeal for
Respiratory Neoplasms denials by:
Understanding the Issue at Hand
Providing a Road Map for the Reviewer
Presenting a Preponderance of Best Evidence
Understand how to tailor appeals to the
Administrative Law Judge
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24. Understanding the Issue
at Hand
Top target MS DRG during RAC demonstration
project
Historically have been identified as problematic DRGs
National Validation Study: HHS-OIG recommended review of
admissions
Short hospitalization with relatively hi h unnecessary
Sh t h it li ti ith l ti l high
admission rates
PEPPER data (FY 2007)
Error rate of 11%
DRG changes: 5% ; Admission denials: 6%
Key Learning: Respiratory Neoplasms expected to
maintain status with the permanent RAC program especially
with Medical Necessity audits.
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25. Understanding the Issue
at Hand
Usually an “outlier” inpatient case
outlier
Rarely need inpatient admissions
Short hospitalization
Admitted when patient presents with complications
and/or for management of co morbidities
Bleeding
Obstructive
Hormonal (ectopic production) etc.
Occupational and Social issues
Smoking
Coal mining
Asbestos e pos e
exposure
Key Learning: Most patients with respiratory neoplasms are treated
as outpatient hence look for documentation why index case is inpatient
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26. The Appeal Algorithm
NCD
LCD
COMMUNITY
STANDARDS OF
MEDICAL CARE
TREATING OR
LIMITATION ATTENDING
OF LIABILITY PHYSICIAN RULE
RULE
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27. NCDs & LCDs
NCD
Ensure effective on the date of service (may have been retired)
Aprepitant for Chemotherapy-Induced Emesis (110.18)
Certain Drugs Distributed by the National Cancer Institute
(110.2)
Erythropoesis Stimulating Agents (ESAs) in Cancer and
Related Neoplastic Conditions (
p (110.21)
)
LCD
Check with your FI etc.
Key Learning: The ALJ is bound by the NCDs however may
consider the LCDs at his/her discretion
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28. Providing a Road Map
Justification of Medical Necessity
J tifi ti f M di l N it
The arguments presented below justify the medical necessity of hospital services. Just as importantly, the arguments justify that
the hospital services provided are “generally accepted by the professional community as being safe and effective treatment.”
Signs and Where Skilled Outcome of Source of
Symptoms or Documented Intervention(s) Intervention Recommendation
Complications
Drowsiness, Physician’s Intubated; I.V. Mental status Dr. Miller (see
Confusion, admission hypertonic changes Nephrology
Seizures notes dated saline at reversed and Consult notes
3/10/2010; 125mL/h for 3 patient no dated 3/10/2010;
*Hyponatremia entered hours page 32 (of 175)
longer had
electronically of the Medical
seizures
by Dr. Glenn; Record
Page 27 (of 175)
of the Medical
Record
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29. Preponderance of
Evidence
ACCP EVIDENCE-BASED GUIDELINES
American College of Chest Physicians
Health and Science Policy Committee
Diagnosis and management of lung
cancer
Reviewed annually for new developments
Most current ACCP guidelines for lung cancer
were published in the September 2007
supplement edition of CHEST
American College of Chest Physicians. (2007). Diagnosis
and Management of Lung Cancer: ACCP Guidelines.
CHEST: 132 (3suppl.)
http://chestjournal.chestpubs.org/content/132/3_suppl
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30. Preponderance of
Evidence
• ACCP PUBLICATIONS
• HOME
• CURRENT ISSUE
• ARCHIVE
• FEEDBACK
• SUBSCRIBE
• ALERTS
• HELP
Table of Contents
September 1 2007; 132 (3 suppl)
1,
Diagnosis and Management of Lung Cancer: ACCP Guidelines
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31. Preponderance of
Evidence
American Society of Clinical Oncology
(ASCO)
Non small cell lung cancer (NSCLC) guidelines
American Society for Clinical Oncology (ASCO).
(2009). Clinical Practice Guideline, Lung Cancer.
http://www.asco.org/ASCOv2/Practice+%26+Guidelines/
p g
Guidelines/Clinical+Practice+Guidelines/Lung+Cancer
Other professional associations
As applicable to the management of complications or
co morbidities
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32. Parting Thoughts
Use the guidelines that were available and in effect at the
Use the guidelines that were available and in effect at the
time the services were provided, coded, and billed!
Provide clear and accurate reference information,
including URLs.
Include all supporting guidelines in full text documents
pp gg
(the pertinent pages) as attachments to your appeal.
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33. Summary
Best Practice for Appeal
Determine if documentation in the chart
supports an appeal
Support the coding decision with:
ICD‐9‐CM Coding Guidelines
IC 9 CM Official Guidelines for Coding and Reporting
ICD‐9‐CM Official Guidelines for Coding and Reporting
American Hospital Association's (AHA) Coding Clinic for ICD‐9‐CM
Support the physician’s decision making process
with evidence based guidelines
Use CMS’s coverage policies and guidelines
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34. Resources
THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM:
An Evaluation of the 3-Year Demonstration, June 2008
https://www.cms.gov/RAC/Downloads/RACEvaluationReport.pdf
Official ICD-9-CM Guidelines for Coding and Reporting
Effective October 1, 2009
http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm
American College of Chest Physicians. (2007). Diagnosis and Management of
Lung Cancer: ACCP Guidelines. CHEST: 132 (3suppl.)
http://chestjournal.chestpubs.org/content/132/3_suppl
American Society for Clinical Oncology (ASCO). (2009). Clinical Practice
Guideline, Lung Cancer.
http://www.asco.org/ASCOv2/Practice+%26+Guidelines/Guidelines/Clinica
htt // /ASCO 2/P ti +%26+G id li /G id li /Cli i
l+Practice+Guidelines/Lung+Cancer
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