Lauree E. Handlon, MS, RHIA, CCS, CPC-H, FAHIMA
Cleverley
+
Associates
NWOHIMA Symposium
February 2014
•
Review Standard Edits vs Custom Edits in determining a
‘Clean Claim’ & how HIM is/should be involved
•
Identify top Outpatient problematic areas and the financial
opportunity, risk, & quality of data involved
•
Including NCCI errors, drug administration, and fracture
treatment & wound repairs
•
Discuss other areas of Outpatient opportunity/risk for focus
including Drug billing & E/M services
•
Provide analysis supporting Inpatient MSDRG Family
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Background: Data Mining Techniques
•
Purpose
:
–
Audit claims data against Medicare reporting requirements
–
Identify trends and patterns in the coding and billing for services
–
Discover outpatient reporting discrepancies due to absent code
submission
•
Focus
:
–
Isolate areas responsible for shift in Service Mix Index
–
Uncover potential lost reimbursement
–
Identify areas of data quality and financial risk
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Standard Edits:
Outpatient Code Editor
(OCE)
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Standard Edits: OCE
•
Background
:
–
The Integrated Outpatient Code Editor (OCE) program edits
patient data to:
1. Edits a claim for accuracy of submitted data
–
Help identify possible errors in coding
2. Assigns Ambulatory Payment Classification (APC) numbers based on
Healthcare Common Procedure Coding System (HCPCS) codes for
payment under the mandated outpatient prospective payment
system (OPPS)
3. Assigns CMS-designated status indicators
4. Assigns payment indicators
5. Computes discounts, if applicable
6. Determines a claim disposition based on generated edits
7. Determines if packaging is applicable
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Standard Edits: OCE
•
Current Version = 15.0 R2
–
87 Edits
•
Excerpt:
Edit
Number Description Generated When… Claim Disposition
01 Invalid diagnosis
The principal diagnosis field (fourth dx position) is blank, there are no
diagnoses entered on the claim, or the entered diagnosis code is not valid for the selected version of the program.
Claim returned to provider
02 Diagnosis and age conflict The diagnosis code includes an age range, and the age is outside that range.
Claim returned to provider
03 Diagnosis and sex conflict
The diagnosis code includes sex designation, and the sex does not match. This edit is bypassed if condition code 45 is present on the claim.
Claim returned to provider
04
Medicare secondary payer alert
a,b
The procedure code has a MSP alert warning indicator. This edit applies to
v1.0 and v1.1 only, and is not applicable for reason for visit diagnosis. Claim suspension 05 E-code as reason for visitb
The first letter of the principal diagnosis code is an E. This edit is not applicable for reason for visit diagnosis.
Claim returned to provider
06 Invalid procedure code The entered HCPCS code is not valid for the selected version of the program.
Claim returned to provider
07 Procedure and age conflict c N/A
Claim returned to provider
08 Procedure and sex conflict
The sex of the patient does not match the sex designated for the procedure coded on the record. This edit is bypassed if condition code 45 is present on the claim.
Claim returned to provider
The procedure code has a Non-covered for reasons other than statute service flag
or
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Standard Edits: OCE
•
National Correct Coding Initiative (NCCI)
Edit
Number Description Generated When…
Claim
Disposition Edit Disposition Definition
20
Component of a
comprehensive procedure that is notallowed even if
appropriate modifier is present
The procedure is identified as part of another procedure on the claim coded on the same day, where the use of a modifier is not appropriate. Only the code in column 2 of a code pair is rejected; the column 1 code of the pair is not marked as an edit.
Line item rejection
The claim can be processed for payment with some line items rejected for payment (i.e., the line item can be corrected and resubmitted but cannot be appealed).
40
Component of comprehensive procedure that would be allowed if appropriate modifier were present
The procedure is identified as part of another procedure on the claim coded on the same day, where the modifier was either not coded or is not an NCCI modifier. Only the code in column 2 of a code pair is rejected; the column 1 code of the pair is not marked as an edit.
Line item rejection
The claim can be processed for payment with some line items rejected for payment (i.e., the line item can be corrected and resubmitted but cannot be appealed).
Column 1/
Column 2
Potentially
Allowed
(OCE Edit 40)
NEVER
Allowed
(OCE Edit 20)
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Standard Edits: OCE
•
National Correct Coding Initiative (NCCI) – Tables available
from CMS
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OCE Results-
What are Hospitals
doing?
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OCE Results
(Pre-Scrubbed)
–
Example Facility
Note:
Highlighted represent potential reimbursement
related OCEs
OCE Edit Description
Edit Disposition Total Occurrences % of Total
Estimated Opportunity
1
Invalid diagnosis
Claim RTP
4
0.08%
6
Invalid procedure code
Claim RTP
19
0.40%
$2,508
8
Procedure and sex conflict
Claim RTP
2
0.04%
17
Inappropriate specification of bilateral procedure
Claim RTP
14
0.30%
20
Component of a comprehensive procedure that is not
allowed even if appropriate modifier is present
Line Item
Rejection
149
3.16%
21
Medical visit on same day as a type T or S procedure
without modifier 25
Claim RTP
221
4.69%
$35,195
28
Code not recognized by Medicare; alternate code for same
service available
Line Item
Rejection
255
5.41%
$14,581
40
Component of comprehensive procedure that would be
allowed if appropriate modifier were present
Line Item
Rejection
2,375
50.41%
$81,699
42
Multiple medical visits on same day with same revenue
code without condition code G0
Claim RTP
18
0.38%
43
Transfusion or blood product exchange without
specification of blood product
Claim RTP
3
0.06%
$518
48
Revenue center requires HCPCS
Claim RTP
1,573
33.39%
62
Code not recognized by Medicare; alternate code for same
service available
Claim RTP
3
0.06%
$939
71
Claim lacks required device code
Claim RTP
75
1.59%
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•
OCE - Top 10 Code errors
OCE Results
(Pre-scrubbed)
– Example Facility
OCE
Edit Description
HCPCS/
Rev
Code
Code Definition
Occurrences
21
Medical visit on same day as a type T or S
procedure without modifier 25
99283 Emergency dept visit
1,237
21
Medical visit on same day as a type T or S
procedure without modifier 25
99284 Emergency dept visit
957
48 Revenue center requires HCPCS
481
Cardiology Cardiac Cath Lab
509
48 Revenue center requires HCPCS
750
Gastrointestinal Services General
461
40
Component of comprehensive procedure that
would be allowed if appropriate modifier were
present
94664 Aerosol or vapor inhalations
351
48 Revenue center requires HCPCS
360
Operating Room Services General
347
40
Component of comprehensive procedure that
would be allowed if appropriate modifier were
present
96365 Ther/proph/diag iv inf, init
318
21
Medical visit on same day as a type T or S
procedure without modifier 25
99282 Emergency dept visit
251
28
Code not recognized by Medicare; alternate code
for same service available
80100 Drug screen
228
40
Component of comprehensive procedure that
would be allowed if appropriate modifier were
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Reimbursement & Data Quality
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•
> 1 million claims involve at least 1 NCCI error
•
Line Item Rejection – Risk & Opportunity
–
Risk: Medicare IS paying some of the error lines =
~ $36 million
–
Opportunity: ~ $6.2 million
OCE Results (POST-Scrubbed) – All US
No.
State
Lines with
Error
Total Lines
Line
Error
Rate
Claim
Error
Rate
Total
Potential
Risk
1 Iowa
43,349
10,035,634
0.4%
1.2%
$ 2,162,660
2 Illinois
70,869
31,027,232
0.2%
0.7%
$ 1,956,196
3 Wisconsin
41,175
13,175,415
0.3%
0.9%
$ 1,889,095
4 Minnesota
43,209
11,854,523
0.4%
1.1%
$ 1,837,403
5 Nebraska
23,588
4,690,961
0.5%
1.5%
$ 1,664,171
24 Ohio
23,845
26,488,236
0.1%
0.3%
$ 660,986
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Custom Edits
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Custom Edits
•
Background
:
–
Common data relationships Standard Edits/OCE does NOT
incorporate
•
Reverse of some OCE edits
•
Payer-specific rules
•
Specific provider related problematic areas
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Custom Edits – C+A’s Areas of Focus
TITLE
DESCRIPTOR
Chemo Administration
A chemotherapy drug is present without chemotherapy administration.
Contrast Procedure
A contrast material is reported without a contrast-related procedure.
Drug Administration
A pharmaceutical item requiring injection or infusion is present without the
administration procedure. This indicator excludes surgery, cardiac catheterization lab,
and gastrointestinal service claims.
Emergency Department E/M
Revenue code 45X is present without an E/M Level.
Fracture/Dislocation Repair
A fracture diagnosis code is present on an emergency room claim without a fracture
treatment procedure.
Laboratory Add-on Code without Parent
Code
A laboratory add-on procedure (CPT codes 80000-89999) is present without an
appropriate primary procedure.
Other Add-on Code without Parent Code
Another add-on procedure (CPT codes 90000-99602, excluding E/M services) is present
without an appropriate primary procedure.
Pacemaker Procedure
Revenue code 275 is present without the associated pacemaker procedure.
Pharmacy Charge
A chemotherapy or non-chemotherapy drug administration procedure is present without
pharmacy charges in revenue code 25X or 63X.
Radiology Add-on Code without Parent Code
A radiology add-on procedure (CPT codes 70000-79999) is present without an
appropriate primary procedure.
Specimen Removal
A pathology exam is present without a biopsy or specimen removal procedure.
Surgery Add-on Code without Parent Code
A surgical add-on procedure (CPT codes 10000-69990) is present without an appropriate
primary procedure.
Transfusion
A blood product is present without a transfusion procedure.
Venipuncture
A laboratory test requiring a venous blood draw is present without venipuncture.
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Custom Edit Results-
What are Hospitals
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Opportunity = > $337 million
•
Top 5 States by Opportunity ($)
•
Top 5 States by Error Rate (%)
Custom Edit Results (POST-Scrubbed) – All US
No.
State Name
Custom Edits
Error Rate
Overall Total Potential
Opportunity
1
California
14.6%
$ 27,390,848
2
Texas
16.4%
$ 17,768,534
3
New York
16.5%
$ 13,627,809
4
Florida
17.9%
$ 12,373,600
5
Illinois
10.8%
$ 9,553,940
11
Ohio
10.9%
$ 6,561,117
No.
State Name
Custom Edits
Error Rate
Overall Total Potential
Opportunity
1
Delaware
23.3%
$ 892,401
2
Rhode Island
22.8%
$ 549,456
3
Utah
20.1%
$ 821,908
4
New Mexico
19.2%
$ 1,338,619
5
Florida
17.9%
$ 12,373,600
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•
Top 5 Custom Errors by Opportunity ($)
•
Top 5 Custom Errors by Error Rate (%)
Custom Edit Results (POST-Scrubbed) – All US
Indicator Description Eligible Missing
Estimated Total
Payment Error Rate
Fracture/Dislocation Repair 531,228 349,042 36,475,611 65.7%
SC/IM Immune Globulin Administration Procedure 807 430 11,689 53.3%
Contrast Procedure 126,763 62,004 18,416,174 48.9%
Wound Repair 617,776 243,652 20,414,242 39.4%
Venipuncture 11,533,516 4,007,554 12,022,662 34.7%
Indicator Description Eligible Missing
Estimated Total
Payment Error Rate
Drug Administration 5,767,781 702,437 51,367,516 12.2%
Other Add-on Code without Parent Code 6,562,987 177,441 39,321,746 2.7%
Fracture/Dislocation Repair 531,228 349,042 36,475,611 65.7%
Angiography/Atherectomy 73,608 7,038 33,127,435 9.6%
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Custom Edit Results – Example Hospital
Category A
Category B
Category C
Description
High probability or error
Lesser probability
of error
Possible data integrity
issue
9
Indicators Evoked
7 Indicators Evoked
3
Indicators Evoked
-Drug Administration
-Specimen Exam
-QI - Specimen Removal
(Lab Only)
-Specimen Removal
-Pacemaker Procedure
-QI - Venipuncture
-Venipuncture
-Contrast Material
-QI - Specimen Removal
-Transfusion
-Contrast Procedure
-ED E/M
-Fracture/Dislocation
Repair
-Pharmacy Charge
-Wound Repair
-Lab Add-on w/o Parent
-Venipuncture POC
-Other Add-on w/o Parent
-SC/IM IG Admin
Results
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•
Drug Administration:
A pharmaceutical item requiring injection or infusion is present
without the administration procedure. This indicator excludes surgery, cardiac catheterization lab,
and gastrointestinal service claims.
Top 5 HCPCS
Indicator Information
Code Information
No.
Catego
ry
Description
Type
Value
Description
Occurrences
1
A
Drug Administration HCPCS Code
J1650 Inj enoxaparin sodium
75
1
A
Drug Administration HCPCS Code
J2405 Ondansetron hcl inj 1 mg
61
1
A
Drug Administration HCPCS Code
J2270 Morphine sulfate injection
48
1
A
Drug Administration HCPCS Code
J3480 Inj potassium chloride
45
1
A
Drug Administration HCPCS Code
J0696 Ceftriaxone sodium injection
37
Total Potential Missed Claims = 780
Error Rate = 10.1%
Total Potential Missed Payment = $66,340
Custom Edit Results – Example Hospital
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•
Missing Drug Administration – Claim Example
RevCode HCPCS HCPCS Definition Mod Units Charge Cost
Medicare Payment APC SI OCE Errors BCQ Errors Comments 0300 84100 Assay of phosphorus 1 $ 105.20 $ 20.22 $ 6.52 0000 A 0300 84484 Assay of troponin, quant 1 $ 219.40 $ 42.17 $ 13.53 0000 A 0300 85025 Automated hemogram 1 $ 119.80 $ 23.03 $ 10.69 0000 A 0300 80053 Comprehen metabolic panel 1 $ 340.60 $ 65.47 $ 14.53 0000 A 0300 83735 Assay of magnesium 1 $ 111.50 $ 21.43 $ 9.21 0000 A 0300 81001 Urinalysis, auto w/scope 1 $ 81.75 $ 15.71 $ 4.35 0000 A 0300 82550 Assay of ck (cpk) 1 $ 124.85 $ 24.00 $ 8.95 0000 A 0300 36415 Drawing blood 1 $ 27.35 $ 5.26 $ 3.00 0000 A 0300 87186 Antibiotic sensitivity, MIC 1 $ 153.90 $ 29.58 $ 11.88 0000 A 0300 87077 Culture Aerobic Identify 1 $ 25.45 $ 4.89 $ 11.11 0000 A 0300 87088 Urine bacteria culture 1 $ 181.15 $ 34.82 $ 11.13 0000 A 0324 71010 Chest x-ray 1 $ 341.70 $ 58.15 $ 52.32 0260 X 0450 99282 Emergency dept visit 1 $ 448.05 $ 170.96 $ 104.95 0613 V
0636 J0696 Ceftriaxone sodium injection 4 $ 189.24 $ 39.37 $ - 0000 N 1 Missing Drug Administration procedure
$ 2,469.94 $ 555.06 $ 262.17
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•
Specimen Removal:
A pathology exam is present without a biopsy or specimen removal
procedure.
•
Specimen Removal – Claim Example
Revenue
Code HCPCS HCPCS Definition Mod Units Charge Cost Payment APC Status OCE Errors
BCQ
Errors Comments
0255 A9579 Gad-base MR contrast NOS,1ml 1 $ 26.00 $ 5.53 $ - 0000 N 0272 1 $ 245.00 $ 81.22 $ - 0000 N
0312 88305
Level IV - Surgical pathology, gross and microscopic examinationAbortion - Spontaneous/Missed Artery, Biopsy Bone Marrow, Biopsy BoneExostosis Brain/Meninges, Other than for Tumor Resection Breast,Biopsy Breast, Reduction Mammoplasty
Bronchus, Biopsy Cell 1 $ 434.00 $ 53.21 $ 33.20 0343 X 2
Missing Specimen Removal procedure
0402 76942
Ultrasonic guidance for needle biopsy, radiological
supervision andinterpretation 1 $ 792.00 $ 74.30 $ - 0000 N 0402 76882 Us xtr non-vasc lmtd 1 $ 721.00 $ 67.64 $ 56.74 0265 S 0489 1 $ 0.01 $ - $ - 0000 E 48
$ 2,218.01 $ 281.90 $ 89.94
Custom Edit Results – Example Hospital
Total Potential Missed Claims = 49
Error Rate = 4.2%
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•
Wound Repair:
A laceration- or wound-related diagnosis is present
on an emergency room claim without a wound repair procedure.
•
Fracture Repair:
A fracture diagnosis code is present on an
emergency room claim without a fracture treatment procedure.
Custom Edit Results – All US
Indicator Description Eligible Missing
Estimated Total
Payment Error Rate
Fracture/Dislocation Repair 531,228 349,042 36,475,611 65.7%
SC/IM Immune Globulin Administration Procedure 807 430 11,689 53.3%
Contrast Procedure 126,763 62,004 18,416,174 48.9%
Wound Repair 617,776 243,652 20,414,242 39.4%
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•
Wound Repair:
A laceration- or wound-related diagnosis is present
on an emergency room claim without a wound repair procedure.
•
Fracture/Dislocation Repair:
A fracture/dislocation diagnosis
code is present on an emergency room claim without a fracture
treatment procedure.
Custom Edit Results – All US
Code Information
Type Code Description
ICD-9 Diagnosis Code 812.00 FX UP END HUMERUS NOS-CL ICD-9 Diagnosis Code 822.0 FRACTURE PATELLA-CLOSED ICD-9 Diagnosis Code 824.8 FX ANKLE NOS-CLOSED ICD-9 Diagnosis Code 825.25 FX METATARSAL-CLOSED ICD-9 Diagnosis Code 821.00 FX FEMUR NOS-CLOSED ICD-9 Diagnosis Code 821.29 FX LOW END FEMUR NEC-CL ICD-9 Diagnosis Code 823.00 FX UPPER END TIBIA-CLOSE ICD-9 Diagnosis Code 824.0 FX MEDIAL MALLEOLUS-CLOS ICD-9 Diagnosis Code 831.04 DISLOC ACROMIOCLAVIC-CL ICD-9 Diagnosis Code 817.0 MULTIPLE FX HAND-CLOSED
Code Information
Type Code Description
ICD-9 Diagnosis Code 881.00 OPEN WOUND OF FOREARM ICD-9 Diagnosis Code 881.01 OPEN WOUND OF ELBOW ICD-9 Diagnosis Code 891.0 OPEN WND KNEE/LEG/ANKLE ICD-9 Diagnosis Code 873.0 OPEN WOUND OF SCALP ICD-9 Diagnosis Code 882.0 OPEN WOUND OF HAND ICD-9 Diagnosis Code 873.42 OPEN WOUND OF FOREHEAD ICD-9 Diagnosis Code 882.1 OPN WOUND HAND-COMPLICAT ICD-9 Diagnosis Code 870.0 LAC EYELID SKN/PERIOCULR ICD-9 Diagnosis Code 879.8 OPEN WOUND SITE NOS ICD-9 Diagnosis Code 891.1 OPEN WND KNEE/LEG-COMPL
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Other Audits:
Outpatient Drug
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Results – Example Hospital
•
Focus on reimbursement discrepancy and high costs using
the National Drug Code (NDC)
•
Reimbursement Opportunity = $
154,736
Drug-Items to Review
Drug Usage Classification
Total
Single-Use
Multi-Use
Unknown
Review HCPCS Codes
1
1
1
3
Review Units
9
0
4
13
Review Payment
9
0
2
11
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Results – Example Hospital
Top 5 NDCs = $138,160 in potential reimbursement opportunity
Example:
NDC Code Trade Name Claim HCPCS APC Code Current APC Status APC Payment Original Volume Volume in CMS Units Volume Difference Original Payment Proposed Payment Payment Difference Payment Percent 59075-0730-15 TYSABRI 20 MG/ML J2323 9126 K $ 11.59 24 7,200 -7,176 $ 271 $ 81,153 $ 80,882 .3 67919-0011-01 CUBICIN (PF) 500 MG J0878 9124 K $ 0.54 77 34,000 -33,923 $ 41 $ 18,075 $ 18,034 .2 50242-0085-27 ACTIVASE (W/DILUENT) 100 MG J2997 7048 K $ 49.22 103 400 -297 $ 4,976 $ 19,502 $ 14,526 25.5 57894-0030-01 REMICADE (S.D.V.,PF) 100 MG J1745 7043 K $ 65.18 126 340 -214 $ 8,016 $ 21,615 $ 13,598 37.1 50242-0040-62 XOLAIR 150 MG J2357 9300 K $ 23.09 17 510 -493 $ 383 $ 11,502 $ 11,119 3.3 -42,103 $ 138,160Information from the National Drug Code (NDC) Directory and the Submitted Data
NDC Code APC Code Current APC Status APC Payment Trade Name Non-Proprietary
Name Package Dosage Form
Drug Usage Type Route of Administration 67919-0011-01 9124 K 0.54 CUBICIN (PF) 500 MG Daptomycin
1 VIAL, SINGLE-USE in 1 CARTON (67919-011-01) > 10 mL in 1 VIAL, SINGLE-USE INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION SINGLE INTRAVENOUS
Billing Information from the NDC Crosswalk
NDC HCPCS HCPCS Description CMS Billing Amount CMS Billing Unit Conversion Factor J0878 INJECTION, DAPTOMYCIN, 1 MG 1.00 MG 500.00
Volume and Payment Analysis
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Other Audits:
E/M Levels
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Results – Example Hospital
Emergency Department E/M Level Distribution:
CMS 2012 (Outpatient claims volume only)
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MS-DRG Family Distribution Analysis
•
Process:
– Review MSDRG family distribution in 2012 public Medicare compared to identified
peers and national benchmarks
– Based on above review, identify “families” showing reimbursement potential if
coding distribution was similar to peers and national benchmarks
– Examine CC and MCC diagnosis code frequency for identified families to provide
information on potential undocumented diagnosis codes
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Five Identified Families
MSDRG Family
Potential Medicare
Reimbursement Shift
if Coding Pattern
Moved to All U.S.
CMI*
Cardiac valve & Other major Cardiothoracic Procedures w/o Cardiac Cath
[219_220_221]
$178,742
Extracranial Procedures [037_038_039]
$114,620
Ventricular Shunt Procedures [031_032_033]
$61,003
Cardiac valve & Other major Cardiothoracic Procedures w Cardiac Cath
[216_217_218]
$28,111
Coronary Bypass w/o Cardiac Cath [235_236]
$23,314
TOTAL
$405,790
*Represents Medicare data only – so – potential could be larger if other payers have Medicare payment methods. Potential is subject to appropriate documentation.
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Family CMI
(Higher value implies
more cases in CC/MCC
MS-DRG)
Example Hospital
All Payer
5.971
6.005
Peer 1
6.672
Peer 2
6.441
All US
6.170
REIMBURSEMENT DIFFERENCE IF CMI AT US GROUP:
$178,742 [
(6.170 – 5.971) x $7220 DRG Base x 124 Family Volume
]*
Cardiac valve & Other major Cardiothoracic Procedures w/o
Cardiac Cath [219_220_221]
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Dx
Definition
CC Status
Current
(FY13)
% Example
Facility
%
Peer 1
%
Peer 2
%
All US
51851
ACUTE RESPIRATORY FAILURE
FOLLOWING TRAUMA AND SURG
MCC
6.5%
13.5%
19.0%
9.4%
51881 ACUTE RESPIRATRY FAILURE
MCC
3.3%
5.4%
9.5%
6.1%
5845
AC KIDNY FAIL, TUBR NECR
MCC
1.1%
18.9%
4.8%
4.9%
78551 CARDIOGENIC SHOCK
MCC
1.7%
5.4%
4.8%
3.8%
44101 DSCT OF THORACIC AORTA
MCC
1.7%
2.7%
9.5%
3.1%
2851
AC POSTHEMORRHAG ANEMIA
CC
20.5%
40.5%
38.1%
39.2%
5180
PULMONARY COLLAPSE
CC
17.9%
10.8%
14.3%
16.5%
5119
PLEURAL EFFUSION NOS
CC
23.9%
27.0%
23.8%
14.3%
9971
SURG COMPL-HEART
CC
6.0%
18.9%
9.5%
13.5%
5849
ACUTE KIDNEY FAILURE NOS
CC
6.8%
8.1%
19.0%
12.4%
Top Five MCC and CC Diagnosis Codes Utilized by US Group
Cardiac valve & Other major Cardiothoracic Procedures w/o
Cardiac Cath [219_220_221]
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Key Take-away Points
• Standard Edits & Custom Edits
• Opportunities, Risk, and Data Quality
• Issue for All Payers, not just Medicare
• Is your claim editor working? Are errors being resolved
before submission at your facility?
– Conduct frequent, independent reviews of claims editing
– Focus on risky areas of combination coding
• Specimen Removal procedures
• Surgical Add-ons
• Emergency Department coding
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