Wiki Inpatient- Capturing Secondary DX Appropriately

[arkassabaum]

Hello I am looking for feedback specifically for Inpatient visits. Currently, I follow the below advice for IP auditing. For OP, I use M.E.A.T to help guide coders and other auditors on my team for capturing SDX. Our facility does not specifically apply M.E.A.T to our IP area at this time. However, I am looking to further expand on defining what constitutes as 'monitored, evaluated, and/or treated.' We have IP cases that range from simple, straighforward 2 day stays to complex/academic over 14 day stays. Usually it is fairly straightforward but sometimes we have cases that arent so cut and dry, and many of us have differing opinions on the matter. I was hoping to poll other coders/auditors. Do you implement M.E.A.T for IP as well or do you have other information to further identify "monitored, evaluated, and/or treated"

"Secondary diagnosis codes are assigned to all diagnoses that exist at the time of admission or develop after admission and are monitored, evaluated, and/or treated.

The UHDDS item #11-b defines Other Diagnoses as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay.

For reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring:

clinical evaluation; or
therapeutic treatment; or
diagnostic procedures; or
extended length of hospital stay; or
increased nursing care and/or monitoring."

 

[TThivierge]

Hi
The inpatient runs on diagnosis codes and sequencing of importance of illness presented for the inpatient status. All these treating dx are linked to one or more of the 761 MS DRG per inpatient stay. The secondary dx should of course be listed if complications occur and related to reason & pertinent to the admission. All dx should be included related , procedures, and comorbidities too. I agree what you have but the TAMPER documentation guide can assist more during the inpatient status. Thus involves reading all face sheets, labs, progress notes, med administration and treatments. See data below ......
There are several tools MRA auditors use to assess documentation guides. Two popular ones are MEAT and TAMPER:
MEAT = monitor, evaluate, assess, or treat. MEAT helps coders choose supporting diagnosis codes for rendered services. Some think this acronym does not address all diagnoses that can be reported for risk adjustment coding because there are more scenarios that qualify a diagnosis code as current or active for risk adjustment purposes. I believe MEAT is more of outpatient status.
TAMPER = treatment, assessment, monitor/medicate, plan, evaluate, or referral. TAMPER helps coders address diagnoses in question that are presented in a list or are noted with a “history of” description. If a coder believes a diagnosis is current but it is listed under Active Problems, Ongoing Problems, Chronic Problems, Past Medical History (PMH), etc., the coder should ask, “Did the provider TAMPER with the diagnosis on the DOS?” If the answer is yes, the diagnosis is current. If the answer is no, the diagnosis is not current. Some providers are uncomfortable reporting diagnoses not currently being treated or addressed and may choose to report only the diagnoses that are in the assessment portions of the encounter documentation. This is problematic in terms of risk adjustment, as well as care management. For example, medications that can be used for several different conditions do not help to support an active diagnosis unless they are linked in some way. Reference is https://www.aapc.com/blog/48557-assess-documentation-to-validate-risk-adjustment-coding/ Sept 2019, AAPC HC Billing Journal.

Well I hope helped you some with this issue
Lady T

diagnosis codes, diagnosis coding