The Perversion of Coding Practices & Reimbursement Policies

Submitted by hci3-usr on Saturday, November 14, 2015 - 12:19

Newtown, CT – November 13, 2015

Few diagnosis codes exemplify the perversion of coding practices and reimbursement policies more than the one for Acute Blood Loss Anemia – From a purely clinical standpoint, anemia resulting from acute blood loss usually occurs as a result of trauma, or a surgery during which the patient had excessive bleeding. In other words, it’s not your run-of-the-mill blood loss from routine surgery. Being anemic, in particular after an invasive procedure, is not a good thing. Most consumers would likely interpret that event as a complication from the surgery. But here’s the funny thing (or maybe the sad thing), a few years ago, as we were launching several implementations of the PROMETHEUS Payment model, we noticed that in some of the pilot sites almost all the patients undergoing surgery had a complication, and the complication was acute blood loss anemia. When the surgeons were queried about this apparently troubling trend, they couldn’t explain why this indication would appear on their patient’s record. We recently had a similar discussion with another surgical group which yielded this strange question from their coding expert – yes folks, most hospitals and large medical groups employ full time coding experts – “does HCI3 follow coding guidelines in determining which diagnosis codes to include in its definitions of potentially avoidable complications?” Now, after doing this work for many years, I should have lost all of my naïveté, but apparently not. So I asked for clarification about which coding guidelines because for us, if it’s bad for the patient, it gets included as a potentially avoidable complication. But that’s not what “coding guidelines” suggest.

What this means to you – There’s a large business that has emerged from the complex and intertwined rules that govern Medicare reimbursement. And that business is euphemistically referred to as coding guidelines, and here’s an excerpt: “Concerned surgeons can be reassured that the code for acute blood loss anemia (285.1) is not classified as a “complication of surgery.” This diagnosis will not adversely impact a surgeon’s complication rates or quality scores. Under the Medicare MS-DRG methodology code 285.1 is considered a complication/ comorbidity (CC) and code 280.0 is not. Therefore incorrect code assignment has potential reimbursement implications. It is also important to note that cases with code 285.1, reported as the only CC diagnosis was one of the target areas of the RAC (Recovery Audit Contractors) pilot demonstration project and is still under scrutiny.” The upshot of this buzz-mumble is simple. If hospital or surgical group staff code a patient as having had acute blood loss anemia, not only doesn’t it count as a bad event, it actually will bump them up in reimbursement. That’s because, as absurd as it sounds, when a patient experiences certain complications, Medicare will pay more. But private sector payers won’t, and HCI3’s episode definitions considered it a potentially avoidable complication, as it should be. All of this points out how completely perverse it is for any payer, and especially Medicare, to provide higher payment for worse care. All that’s changing, which is good news for patients, and perhaps one day the nurses that have become coding experts can go back to caring for patients rather than dollars.


Francois Sig