Inpatient Facility Coding & Compliance Alert

Know the facts and break the fall that “doctor shopping” has wrought

How compliant are you in monitoring your patients’ opioid use? Not keeping tabs on this could put you in line for some unwelcome scrutiny.  A statistical brief from the Agency for Healthcare Research and Quality (AHRQ) published Aug. 12 presents startling facts that every hospital needs to know. Read on to discover what the analysis shared about the steep rise in opioid dependence, abuse, poisoning, and adverse effects in inpatients. 

The basics: Narcotic overuse and abuse is a major health issue in the country. This analysis was based on data from the Healthcare Cost and Utilization Project (HCUP) 1993-2012 Nationwide Inpatient Sample (NIS) that is based on the number of adult discharges in hospitals from 44 States. Overuse included unintentional and deliberate abuse of a prescription i.e., taking a greater dose than prescribed, taking a drug prescribed for someone else, and taking the drug along with alcohol.

High points from the report included:

• Upward trend over the years: The rate of hospital stays involving opioid overuse among adults increased more than 150 percent between 1993 and 2012, from 116.7 to 295.6 stays per 100,000 population. This means a 5 percent increase annually.

• Men vs. women: In 1993, males had a higher rate of inpatient stays involving opioid overuse than females (144.0 vs. 91.6 stays per 100,000) but this difference in rates decreased over time. Moreover, female inpatient stays saw a greater annual increase in opioid overuse of 6.3 versus 4.0 percent for males.

• Age trends: From 1993 to 2012, the rate of hospital stays involving opioid overuse among adults aged 25-44 years increased by 1.7 times, while the rate increased more than 3-fold for adults aged 18-24 years and more than 5-fold for each of the three oldest age groups (45-64, 65-84, and 85+ years). The average annual increase was highest at 8.9 percent for adults aged 45-84 years.

• Regional trends: In 1993, the Northeast region topped the list of adult hospital inpatient stays involving opioid overuse (264.0 stays per 100,000). However, with time, the Midwest had the largest average annual increase (9.1 percent).

• Medicare vs. third parties: In 1993, Medicaid was billed for nearly 100,000 hospital stays involving opioid overuse—three times higher than the number of stays billed to Medicare and more than twice as billed to private insurance or to uninsured patients. However, Medicare had the most rapid annual growth (10.6 percent) in the number of hospital stays between 1993 and 2012.

• Medicare vs. Medicaid: The proportion of inpatient stays for opioid overuse billed to Medicaid decreased over time, while the proportion billed to Medicare more than doubled.

Question of illness: The study also shows an increase in the average number of secondary diagnosis codes documented in the discharge notes from 2.86 in 1993 steadily increasing to 7.93 in the year 2012.This information is worth analyzing to determine whether we are actually heading forward as a sicker community, whether our providers are documenting more diagnoses, or whether it is all about smarter reimbursement strategies?

Know the Opioid Diagnoses Included

The study used ICD-9-CM codes defining opioid overuse. It included the 304 series with opioid dependence and opioid other dependence, be it unspecified, continuous, episodic, or in remission. It also included the 305 series denoting opioid abuse, 965.00 (Poisoning by opium [alkaloids] unspecified), 965.09 (Poisoning by other opiates and related narcotics), E850.2 (Accidental poisoning by other opiates and related narcotics) and E935.2 (Other opiates and related narcotics causing adverse effects in therapeutic use). The study excluded patients who were admitted due to adverse effects from using illegal drugs like heroin and hallucinogens.

Explanation: The data was extracted from community hospitals, which are defined as short-term, non-Federal, general, and other hospitals. These can include obstetrics and gynecology, otolaryngology, orthopedic, cancer, pediatric, public, and academic medical hospitals. The study excluded facilities focusing on long-term care, rehabilitation, psychiatric, and alcoholism and chemical dependency.

The unit of analysis was the hospital discharge (i.e., the hospital stay), and not the patient. This means that if a person was admitted to the hospital multiple times in one year he would be counted each time as a separate “discharge” from the hospital.

Root cause analysis: It seems the growing practice of “Doctor Shopping” (i.e., seeking narcotic prescriptions from multiple providers) is responsible for the increase in drug use among postoperative orthopedic trauma patients, according to a study “Narcotic Use and Postoperative Doctor Shopping in the Orthopedic Trauma Population” presented at the 2014 Annual Meeting of the American Academy of Orthopedic Surgeons (AAOS). Patients with a history of preoperative narcotic use were 4.5 times more likely to seek out an additional provider. The study therefore cautions the providers to closely monitor narcotic prescriptions and related patient requests following orthopedic and other surgeries.

What you need to do: “Doctors need to inform patients about the risks associated with receiving painkillers from more than one provider,” says Dr. Anupam Jena, Assistant Professor, Health Care Policy at Harvard Medical School in an article on the website http://medicalxpress.com. They published the data analysis of 1.8 million Medicare Part D beneficiaries on Feb 19 in the British Medical Journal.  The study showed that more than 30 percent of patients received painkillers from multiple providers.

“The greater the number of prescribers, the higher the risk of hospitalization,” said study co-author Pinar Karaca-Mandic, Assistant Professor, University of Minnesota School of Public Health in an interview for the website http://medicalxpress.com. “Patients with four or more prescribers were twice as likely to be hospitalized for narcotics-related complications as patients receiving the same number of prescriptions from a single caregiver.” 

Cap the burden of payers: As the Medicaid enrollment among adults is on a steady rise, Medicaid’s share of opioid-related inpatient stays is also likely to increase, thereby adding to the burden. 

Hospitals would need to take stringent measures to cap this narcotic abuse by-

• Screening the patients’ records for a history of drug overuse.
• Take an in-house survey see where we stand in terms of pain “over” management in our facility.
• Disseminating information about the risks of over medication.
• Advisory to abstain from “Doctor Shopping” any further.

Take-home message: “Hospitals should work through their medical staff organizations to increase the sensitivity of physicians to this particular problem” comments Duane C. Abbey, Ph.D., president of Abbey and Abbey Consultants Inc., in Ames, IA.  “These statistics should be studied with care. There is little question that narcotic abuse is increasing. If possible, hospitals should take steps to monitor possible misuse in real time, that is, at the point in which the misuse starts. However, in many cases the information that misuse is occurring will not be available until after the fact.  Follow-up will then be necessary on the part of hospital staff.”