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Top 5 hospital diagnoses and procedures*

Most expensive diagnoses

Spinal cord injury

Infant respiratory distress syndrome

Low birthweight Leukemia

Heart valve disorders

Most expensive procedures

Heart, lung, pancreas and liver transplantation


Most common diagnoses

Liveborn infant

Coronary atherosclerosis and other heart disease

Bone marrow transplantation

Kidney transplantation

Heart valve procedures


Congestive heart failure

Acute myocardial infarction

Most common procedures

Other procedures to assist delivery


Cesarean section Episiotomy

Diagnostic cardiac


*Hospital Inpatient Statistics, 1996, Healthcare Cost and Utilization Project Research Note. AHCPR Publication No. 99-0034. Agency for Health Care Policy and Research, Rockville, Md.

Specifi c examples should be used when educating physi- cians. Organizations can create charts listing a diagnosis and the ICD-10 documentation specifi city needed to accurately code and bill. For example, instead of simply documenting asthma, physicians need to state the severity level of the asthma in ICD-10. So in this case, each ICD-10 severity level for asthma should be presented to the medical staff along with the type of documentation that will be required. Yes, the changes are complex and along with them, the educational process – particularly with physicians – will be arduous. There is no time to panic, but also no time to wait, as 80 percent of an organization’s revenue typically comes from their top 20 percent of cases.

Back to the basics The Program for Evaluating Payment Patterns Electronic

Report (PEPPER) is a proven starting point for boosting coding compliance. Hospitals have used PEPPER reports for decades to identify trends, monitor high-risk areas and compare themselves to other facilities from one quarter to the next. PEPPER reports are based on hospital-specifi c Medicare data and must be a key component of the coding- compliance program. Specifi cally, organizations should look for MS-DRGs within certain major diagnostic categories that are perform- ing at the lowest levels. Suboptimal performance compared to peers is often due to inappropriate documentation. For example, physicians often use slang terms to describe common conditions. Pneumonia may be described only as hospital acquired, community acquired, etc. By neglecting to document the organism causing the respiratory infection, a “simple” pneumonia code is used instead of a more severe or complicated code.

Once identifi ed, these types of issues can be targeted for quality coding reviews, internal audits and education. If performance fails to improve over at least two consecutive quarters, an external audit may be conducted to obtain an unbiased, neutral third-party opinion and uncover underly- ing problems. Poor performance with ICD-9 coding is a sure indica- tor of revenue problems in ICD-10. Organizations that start early by assessing current areas of concern, going back to the basics and conducting frequent, internal and well- documented audits, are better prepared to handle future coding requirements.

The catalyst for better ICD-9 coding The implementation of ICD-10 is a catalyst for im- proved coding performance in ICD-9. The new code set will create a refi ned challenge related to coding and clinical documentation. Greater specifi city will lead to improved patient care, more accurate reimbursement and better data about healthcare populations. However, organizations can’t leverage these benefi ts if the supporting documentation is unclear or incomplete. ICD-10 requirements should be built into all ICD-9 cod- ing compliance and CDI programs today. Programs should: • Include standardized methods to measure coding quality performance and clinical documentation.

• Be conducted regularly. • Incorporate both internal and external auditing prac- tices.

By bolstering coding compliance and CDI programs now, providers should improve documentation, coding and reim- bursement, reduce their risk of recovery audit take-backs and increase CMI. And they’ll be ready come 2013.


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