The RAC & Chest Pain MS-DRG 313

THE RAC and Chest
Pain MS-DRG 313

Charmira Orr BS, LPN,CCS,CPC, CCDS
Intersect Healthcare, Inc
Director of Coding and Auditing

Learning Objectives
1. Participants will review and understand
the RAC and past findings in the
demonstration area to assist in
preparing a defense
2. Participants will recognize how to
translate clinical documentation from
the medical record in regards to MI vs.
Chest Pain into ICD-9 terminology
3. Participants will understand how to
audit the medical record for data
pertaining to Inpatient vs. Observation
status

2010 Intersect Healthcare, Inc. 2

[The RAC and Chest Pain
MS-DRG 313]
 According to CMS Payment reports in 2007 accounted for 20.1%
of paid claim error rates. Ranked #1 of medical unnecessary
admissions
 In Q1FY10 MS-DRG 313 still ranked #1 for reasons for short
stays
 National Length of Stay 2.1 days
 RW 0.5314
 Principal Diagnosis OF MS-DRG 313
- 786.50 Chest pain, unspecified
- 786.51 Precordial pain
-786.59 Chest pain, other
- V71.7 Observation for suspected cardiovascular disease
 Targeted by RAC to validate whether “Short Stay” inpatient
admissions meet Medicare’s medical necessity criteria


MS-DRG 313 Chest pain
Demonstration Findings from NY and Florida : RAC denied
many cases based upon the fact that patients did not meet
clinical criteria for inpatient care
Great concern for one day stays admissions
Inadequate documentation within the medical record
contributed to many of the denials

Coding points for Chest Pain vs. MI

Chest
MI
Pain
Symptom Diagnosis

Coding – to 5th digit to
reflect episode of care
Coding and sequencing
Specifity of the wall
depends on location and
affected-
physician documentation
Electrocardiographic Report

Can be attributed to
Often consist of the
atypical, musculoskeletal,
symptom of Chest Pain in
non-cardiac conditions
which increases in severity


Coding for Chest Pain
 Principal Diagnosis- The principal diagnosis is the condition that is
established after study that is responsible for the admission of the
patient to the hospital for care.
Two or more diagnoses may equally meet the definition for principal
diagnosis. Be aware that there is a difference between admitting a patient
to treat two conditions and two conditions being present at the time of
admission.
 When reviewing the medical record determine whether or not there were
any underlying causes for the chest pain that were documented by the
physician.
If a cause was established, the cause of the chest pain is the principal
diagnosis
 If the principal diagnosis is observation for a suspected cardiovascular
disease, there should be a ruled out principal diagnosis and no symptoms
present.


Observation vs. Inpatient
Highlights


Observation Status

Billed under Outpatient Prospective Payment System ( OPPS)

Chest pain is paid under specific observation Ambulatory Payment Classifications (APCs)

Medicare Coverage requires at least 8 hours of monitoring and is limited to 48 hours
unless FI grants an exception

The hospital is only paid for 24 hours –

Observation status can be changed to Inpatient Status

Hospitals can convert Inpatient case to Outpatient if determined prior to Patient discharge

N/A - convience, preop, recovery after diagnostic testing, and Inpatient only procedures


ICD- 9 Code V71.7
 V71 Category Observation and evaluation for suspected conditions not found
 V71.7 Observation for suspected cardiovascular disease
 Always Principal Diagnosis
 Principal diagnosis for MS-DRG 313
 This code would only be used when a suspected cardiovascular condition is ruled out and no
symptoms for the suspected condition are present. If a symptom is present, the code for the
symptom is used and not a code from category V71. (See Coding Clinic, fourth quarter 1994,
page 47.)
 Other conditions that co-exist at the time of admission may be coded as secondary diagnoses
if they are unrelated to the suspected condition. (See Coding Clinic, fourth quarter 1996,
page 53,and Coding Clinic, March-April 1987, pages 1 and 3-5.)
 Must only be used after study ,examination, and observation that has ruled out
cardiovascular disease
 Physician documentation should include findings that suspect abnormal conditions as
reasons to why order for Observation status- should include a condition to RULE OUT


Inpatient Status

Admission criteria usually based on Decision Trees/ Criteria

Specific symptom or diagnosis

Should include MD H&P Risk Assessment

Should have detailed findings Labs, radiology to support admission

Auditing the Medical Record
Examine

Query Review

Track
Documentation Abstract
Data

Identify Code

Compare

The Process
1. Examine -The medical record to ensure that it is a complete record.
Physician attestation statement and Discharge Summary is on the record,
as well as nurses notes, treatment records and etc..

2. Review - Must review the Entire Medical Record to accurately assign the
principal and secondary diagnosis

3. Abstract- Data from the Medical Record – Worksheet


One Day Stay Worksheet
ADMISSION ORDERS: To Where
Observation ( less than 24hours)
1. Does the medical record have an order for observation status?
Yes or No
2. What is the documented diagnosis :
3. Does the Attending provider state condition can be treated within 24
hour period?
Yes or No
4. If the clinical diagnosis was uncertain at time of order, was it determined
within 24 hours or by patient discharge?
Yes or No
5. Within the nurses notes is there documentation to support the initiation
or arrival of the patient to observation status? If so, date and time:
6. Date and time of the discharge order:
7. Did the patient require a treatment that takes longer than six hours?
Yes or No


Worksheet Continued
INPATIENT
1. DOES THE MEDICAL RECORD HAVE AN ORDER FOR ADMISSION TO
INPATIENT STATUS? YES OR NO

2.DOES THIS STAY MEET THE MEDICARE DEFINITION FOR SHORT STAY:
( ONE DAY ADMISSION) YES OR NO
3.IS THERE AN ORDER TO CHANGE STATUS FROM OBSERVATION; IF
PATIENT WAS IN OBSERVATION? YES OR NO
4.IF PATIENT WAS TRANSFERRED FROM OBSERVATION STATUS; WHAT
WERE THE SPECIFIC CONDITIONS FOR THE TRANSFER?
5. PRINCIPAL DIAGNOSIS LISTED FOR INPATIENT ADMISSION:
6. IS THIS A CHANGE FROM THE ADMITTING DIAGNOSIS? YES OR NO
7.CHRONIC CONDITIONS LISTED AT TIME OF INPATIENT ADMISSION-
8.WERE THESE CONDITIONS TREATED DURING THE COURSE OF THE
STAY? ( LIST INTERVENTIONS AND/OR TREATMENT OR EVALUATIONS)


Worksheet Continued
9. VITALS AT TIME OF ADMISSION:
10. LABS: CARDIAC ENZYMES- POSITIVE TROPONIN LEVELS PT/INR
11. WAS ADMISSION SCREENING CRITERIA SUCH AS INTERQUAL OR MILLIMAN
APPLIED TO THIS RECORD? YES OR NO
12. WAS IMAGING COMPLETED BEFORE ADMISSION OR ANY THAT RELATES TO
ADMISSION
13. EKG COMPLETED: ( DOCUMENT RESULTS- ANY FINDINGS OF ISCHEMIA)
14. WAS A CXR COMPLETED, AND IF SO WERE THERE ANY UNDERLYING
CONDITIONS THAT WERE NOTED THAT MAY CONTRIBUTE TO THE CHEST PAIN?
YES OR NO
15. WERE THERE ANY PROCEDURES PERFORMED WITHIN 24 HOURS OF
ADMISSION YES OR NO
16. ARE THE PROCEDURES LISTED ON THE APC LIST FOR INPATIENT STATUS
ONLY? YES OR NO
17.WAS THE PATIENT ADMITTED FOR AN INPATIENT PROCEDURE? AND IF SO
18.WHAT IS THE MEDICAL NECESSARY REASON FOR THE PROCEDURE?
19. IS THIS A PROCEDURE THAT COULD ONLY BE PERFORMED ON INPATIENT
STATUS? YES OR NO
20. DID THE PHYSICIAN LIST ANY DEFINITIVE OR UNDERLYING CONDITIONS FOR
THE CHEST PAIN


Worksheet Continued
Review of the H&P
PMH i.e.… MI’s,
Risk Factors
Physician Treatment Plan
Does the documentation support treatment beyond 24 hours?
Are there any co morbidities listed that will extend patient stay beyond 24-48 hours and
additional procedures scheduled?
Patient length of stay;___________ Does this stay correlate with the GMLOS for this
DRG? Yes or No
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
Was this record billed with the appropriate status on the claim? Yes or No

Auditing the Medical Record
Continued
4.Code- Reviewer will code from data that they abstracted
5.Compare- codes that they assign to the codes that were billed
6.Identify- any areas in the medical record for areas of uncertainty and
discrepancies
7.Track Data Collected- Highlight areas, photocopy areas in question to
possibly highlight for physician
8.Query- the provider on any discrepancies found. Send them the highlighted
portions of the medical record so that they can view. DO not lead .. Only
identify what is in the record and ask for clarification

Statement of Issue or Discrepancy
Date Initiated
Contact person and Info
Date Query Completed


Additional Sign and Symptoms
Telling the Story
Present on Admission Chronic Conditions Present on Admission

Principal Diagnosis Documentation to support Secondary Diagnosis Procedures DRG Assigned

References
http://www.pepperresources.org/LinkClick.aspx?fileticket=j58QxNsRHRo%3d&tabid=61

http://www.fortherecordmag.com/archives/042610p27.shtml

http://www.pepperresources.org/Data.aspx

http://www.wsha.org/files/64/AHA-PreparingforRACaudits.pdf

http://www.intmed.vcu.edu/home/faculty/billing/observation-inpatient.html#A


Appealing a
Chest Pain One
Day Stay Denial

Denise Wilson, MS RN RRT
Director, Client Education and Performance
Improvement
Intersect Healthcare, Inc.

Learning Objectives
 Understand how to create a successful
medical necessity appeal for Chest Pain
One Day Stay 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


Understanding the Issue
at Hand
 According to the most recent Program for
Evaluating Payment Patterns Electronic Report
(PEPPER) Chest Pain MS-DRG 313 Chest has the
highest one-day stay and discharge total per DRG
nationwide.
 National-level statistical analyses for at-risk
payment errors, from Q2FY2009 through
Q1FY2010, in short-term acute care hospitals found
the sum of Chest Pain One-Day Stay averaged over
$26 million per quarter.

Short-Term Q1FY10 Report; Discharges for most recent 4 Quarters, ending
Q1 FY2010; Nationwide Top 20 MS-DRGs for One-Day Stays

at Hand
“Medically Unnecessary Services includes situations where the
CERT claim review staff identifies enough documentation in
the medical record to make an informed decision that the
services billed to Medicare were not medically necessary.
In the case of inpatient claims, determinations are also
made with regard to the level of care; for example, in some
instances another setting besides inpatient care may have
been more appropriate. If an FI or MAC determines that a
hospital admission was unnecessary due to not meeting an
acute level of care, the entire payment for the admission is
denied.”

CMS November 2009 Medicare FFS Improper Payments Report

at Hand
“Medically Unnecessary Service errors accounted for 1.3% of
the total inpatient dollars allowed during the reporting
period. For inpatient claims, this is often related to hospital
stays of short duration where services could have been
rendered at a lower level of care.”

https://www.cms.gov/apps/er_report/index.asp


at Hand
Medicare Benefit Policy Manual Chapter 4 – Section 290 - Outpatient
Observation Services

“Observation care is a well-defined set of specific, clinically appropriate services,
which include ongoing short term treatment, assessment, and reassessment,
that are furnished while a decision is being made regarding whether patients
will require further treatment as hospital inpatients or if they are able to be
discharged from the hospital.
Observation services are commonly ordered for patients who present to the
emergency department and who then require a significant period of treatment
or monitoring in order to make a decision concerning their admission or
discharge.”
“In only rare and exceptional cases do reasonable and necessary outpatient
observation services span more than 48 hours. In the majority of cases, the
decision whether to discharge a patient from the hospital…or to admit the
patient as an inpatient can be made in less than 48 hours, usually in less than 24
hours.”


at Hand
Medicare Benefit Policy Manual Chapter 1 - Inpatient Hospital Services
Covered Under Part (Rev. 1, 10-01-03)

“The physician or other practitioner responsible for a patient's care at the
hospital is also responsible for deciding whether the patient should be
admitted as an inpatient. Physicians should use a 24-hour period as a
benchmark, i.e., they should order admission for patients who are
expected to need hospital care for 24 hours or more, and treat other
patients on an outpatient basis. However, the decision to admit a
patient is a complex medical judgment which can be made only after
the physician has considered a number of factors, including the
patient's medical history and current medical needs, the types of
facilities available to inpatients and to outpatients, the hospital's by-
laws and admissions policies, and the relative appropriateness of
treatment in each setting.”


at Hand
Factors to be considered when making the decision to admit include such
things as:
• The severity of the signs and symptoms exhibited by the patient;
• The medical predictability of something adverse happening to the
patient;
• The need for diagnostic studies that appropriately are outpatient services
(i.e., their performance does not ordinarily require the patient to
remain at the hospital for 24 hours or more) to assist in assessing
whether the patient should be admitted; and
• The availability of diagnostic procedures at the time when and at the
location where the patient presents.
Admissions of particular patients are not covered or noncovered solely on
the basis of the length of time the patient actually spends in the
hospital.


Providing a Road Map
 From our Appeal Letter Template:
Review of the medical record justifies the need for the level
of care provided based on the severity of the signs and
symptoms exhibited by the patient and the medical
predictability of something adverse happening to the
patient as evidenced by the objective findings on the
Admission History and Physical and test results as follows:

List all objective findings, 1, 2, 3, etc…
To be completed by the client. (List objective findings)

Preponderance of
Evidence
 Use of Screening Tools
 Interqual® Level of Care Criteria
 Milliman Care Guidelines
 CMS does not endorse nor recognize specific screening
tool guidelines for admission purposes

 PEPPER
 http://www.pepperresources.org
 Tools/Unnecessary Admissions
 Tools/DRG Errors


Preponderance of
Evidence
 Evidence Based Guidelines

 Goldman L, Kirtane AJ. Triage of patients with
acute chest pain and possible cardiac ischemia.
Annals of Internal Medicine 2003;139:987-995
 ACC/AHA 2007 guidelines for the management
of patients with unstable angina/non-ST-
Elevation myocardial infarction: a report of the
American College of Cardiology. J Am Coll
Cardiol 2007 Aug 14;50(7):e1-e157


Summary
 Best Practice for Appeal
 Determine if documentation in the chart
supports an appeal
 Support the physician’s decision making process
with evidence based guidelines
 Use CMS’s coverage policies and guidelines


Resources
Short-Term Q1FY10 Report; Discharges for most recent 4
Quarters, ending Q1 FY2010; Nationwide Top 20 MS-DRGs
for One-Day Stays;
CMS CERT Report from November of 2009;
https://www.cms.gov/apps/er_report/index.asp
CMS Manuals; http://www.cms.gov/manuals

Goldman L, Kirtane AJ. Triage of patients with acute chest pain and possible
cardiac ischemia. Annals of Internal Medicine 2003;139:987-995

ACC/AHA 2007 guidelines for the management of patients with unstable
angina/non-ST-Elevation myocardial infarction: a report of the American
College of Cardiology. J Am Coll Cardiol 2007 Aug 14;50(7):e1-e157


The RAC & Chest Pain MS-DRG 313

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