A False Claim by the OIG:
Alleged Upcoding of DRG 416
A Clinical Analysis of Septicemia
C. Gary Hullquist, M.D.
Kathy S. McKenney, R.N.
Septicemia Is Increasing
Recent statistics suggest that factors other than age are contributing to the increased incidence of septicemia. From 1979 (when ICD-9-CM was first implemented in the United States) to 1996, the age-adjusted death rate for septicemia increased by an alarming 78.3% according to the Centers for Disease Control and Prevention. In contrast, age-adjusted death rates for heart diseases, cerebrovascular diseases (strokes) and accidents each declined roughly 30% and malignant neoplasms (cancer) declined 2%. Physicians cannot yet explain the causes for the increase in septicemia, but several hypotheses can be advanced:
- Fewer heart attacks, strokes and accidents are leaving septicemia as an unmasked illness and cause of death. Coding conventions force physicians to specify a primary diagnosis even though multiple factors are present in many cases. A related factor may be earlier and more aggressive surgical interventions to prevent heart attacks and strokes create more risk for septicemia.
- Long-term overuse of antibiotics has increased the number of antibiotic-resistant bacteria capable of infecting the blood.
- Modern pollutants and broader use of agents that have immunosuppressant characteristics (such as cortisone and other steroids) have damaged human immune systems, leaving them more vulnerable to infectious diseases such as septicemia, pneumonia and chronic obstructive pulmonary diseases.
Fear Factor
Despite the documented increase in the frequency of septicemia on a national level and the authoritative coding guidance, physicians are often reluctant to propose the diagnosis of sepsis without a supporting blood culture. Physicians still manage and treat these same patients in an aggressive manner consistent with the seriousness of their condition. The direct loser is the hospital, deprived of more than $2,000 per discharge while it must provide full resources to the acutely ill patient suffering from the clinical symptoms of septicemia. The indirect loser is the physician, who will appear to be an incompetent and inefficient provider when managed care payors and credentialing committees review his high mortality rate and abnormally long lengths of stay for urinary tract infections (DRG 320), which really are downcoded cases of septicemia.
The OIG should prosecute providers who intentionally attribute the diagnosis of septicemia to the patient who does not manifest the clinical evidence of such a serious condition. However, the OIG, HCFA, fiscal intermediaries and providers should focus on the clinical documentation and terminology to support correct coding that, in turn, reflects appropriate severity of illnesses within the Medicare population. DRG 416 and other DRGs targeted by the OIG involve coding guidelines that may require clinical clarifications. Using software tools or superficial profiling that lack a clinical documentation component will not produce an accurate picture of either upcoding or downcoding.
Conclusion
Contrary to the OIG's report, negative or inconclusive blood cultures do not preclude a diagnosis of septicemia and coding to DRG 416 for patients with clinical evidence of the condition. The true error rates for upcoding and downcoding can only be determined by undertaking a detailed review of the clinical documentation at each hospital. Septicemia is a serious syndrome that is significantly increasing in the United States. Providers must carefully develop and document the clinical picture surrounding septicemia in order to improve the quality of care and to justify billings under DRG 416.
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BIOGRAPHIES
Scott C. Withrow, J.D., is a founding partner of Withrow, McQuade & Olsen, LLP, an Atlanta law firm, and author of Managing Healthcare Compliance, published by Health Administration Press.
C. Gary Hullquist, M.D. and Kathy S. McKenney, R.N. are Vice Presidents and shareholders of J.A. Thomas & Associates, Inc., a national hospital and physician consulting firm specializing in clinical documentation.
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© 1999 Scott C. Withrow, C. Gary Hullquist and Kathy S. McKenney. All rights reserved.
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