Medicare Compliance & Reimbursement

Inpatient rehab facilities looking to increase revenue should brush up on their documentation for comorbidities.

A comorbidity is a specific condition that is secondary to the primary reason the patient requires acute care, reminds consultant Ann Lambert Kremer with Baker Newman & Noyes in Portland, ME. And although they're secondary conditions, they can bring in first-rate bucks. "It's nothing to find people leaving behind $200,000 to $1 million by not listing comorbidi-ties," reports consultant Fran Fowler with Fowler Healthcare Affiliates in Atlanta.

The amount of reimbursement a comorbidity carries depends on its acuity level, counsels clinical consultant Ellen Strunk with Restore Therapy Services in Pelham, AL. Under the prospective payment system, comorbidities are broken out into three tiers, "and that's how [the Centers for Medicare & Medicaid Services] calculates the reimbursement a facility will get," she explains. Those considered Tier 1 comorbidities garner the most reimbursement.

Coding tip: "Comorbidity ICD-9 codes entered in section 24 of the IRF [Patient Assessment Instrument] should be used to represent conditions diagnosed either during or after the admission assessment but not including those occurring on the last two days of stay," instructs Kremer.

Caution: Kremer has shared with MLR these three areas you should be extra careful of when coding for patients'comorbid conditions:

1. Do not code in section 24 of the IRF-PAI comor-bid conditions that were resolved during the patient's acute care stay before inpatient rehab admission. "If the comorbidity did not result in additional costs for the inpatient rehab provider, it should not be coded."

2. Many medical record coders aren't educated about the IRF-PPS system and are therefore unaware of IRF-PAI coding guidelines. "As a result, they may not always be coding according to the unique guidelines of this system."

3. Commonly overlooked comorbidities that would result in additional payment if documented include: morbid obesity (278.01), diabetes with neurological manifestations (250.60), polyneuropathy in diabetes (357.2) and renal dialysis status (V45.1).

Many providers don't code for morbid obesity because they are unsure of the definition, says Strunk. "Morbid obesity is defined as a body mass index (BMI) of 40 percent or more or 100 pounds above ideal body weight," offers Kremer.

IRFs should remind physicians to document morbid obesity in their notes so coders are able to code appropriately, suggests Kremer. Dieticians are good about documenting this condition, but physicians often "aren't comfortable putting that label on someone," according to Strunk.

Another comorbidity many providers miss is malnutrition. "Many people don't know how to document malnutrition," Fowler laments. "Anyone who's been in acute care for more than seven days is probably malnourished, because they've lost enough of the essentials that it counts as malnutrition," according to Fowler.

Strategy for success: Share lists of commonly coded comorbid conditions with physicians, Kremer advises. Doing so will increase their awareness of the importance of documenting the conditions and will help physicians remember to include comorbidities in their own reports.

Kremer has shared a sampling of commonly coded comorbidities:

Tier 1: tracheostomy status (V44.0), dependence on respirator (V46.1), kwashiorkor (260), severe malnutrition (262), vocal chord paralysis (478.30);

Tier 2: dysphagia (787.2), renal dialysis status (V45.1), intestinal infections due to other organisms (008.45), cellulites of the leg (682.6), other post op infection (998.59);

Tier 3: morbid obesity (278.01), polyneuropathy in diabetes (357.2), pneumonia organism NOS (486), diabetes with neurological manifestations (250.60), unspecified hemiplagia (342.90).