Physician Advisor Perspective to Avoid a Potential DRG Clinical Validation Downgrade Denial of DRG 853
Be sure your operative procedures are coded correctly.
Procedural titles should not be taken at face value! What the surgeon actually did in the OR may be different than what the surgeon said they did in the OR. If auditors can change the coding of a documented procedure from a valid OR procedure to one that is not, that kicks the case out of the 853-855 set of MS-DRGs, moving the case from a surgical DRG to a lower reimbursing medical MS-DRG.
Pay particular attention to the documentation of excisional debridement. This can be performed by physical therapists at the bedside and still count as a valid OR procedure regardless of performance location. Auditors/CMS/OIG are opposed to the idea that a bedside procedure bumps a medical MS-DRG to a surgical one.
Pay attention to the cause of the infection.
If it can be traced/linked/ascribed to some previous medical intervention, the principal diagnosis should be the corresponding complication code, which may change the MS-DRG.
Be sure sepsis was documented POA.
Remember that the chapter specific coding guidelines state that sepsis is the principal IF the reason for admission is both sepsis and a localized infection. If the patient came to the hospital for some other reason, and that reason is not attributable to sepsis, sepsis is probably not the correct principal diagnosis.
Only charts with single MCCs or CCs will be at risk for having MCCs and/or CCs removed.
Auditors do not waste time reviewing charts with multiple MCCs or CCs. Therefore, make sure single MCC and single CC charts in the MS-DRGs 853 and 854 have rock-solid, consistent and repeated documentation throughout the record, including the D/C summary—and that definitive, clear, widely accepted clinical criteria thresholds were demonstrably reached.
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