develop a performance improvement plan for both documentation and coding that you will present to the Compliance Committee. Be sure to include the issues with Dr. Blacks documentation and Mary Smiths coding quality.

Ethical Coding Scenario

Background

Davenport Hospital is a rural, non-profit, acute care facility with approximately 80 beds. The primary payer for the hospital is Medicare, as the majority of its patients are elderly. Common diagnoses for inpatient admissions primarily consist of Congestive Heart Failure, Pneumonia and complications of Diabetes due to the aging demographic.

Davenport Hospital has just on-boarded a new Chief Financial Officer after having been without a person in the position for almost one year. One of the first areas of business focused on by the CFO was the days in Accounts Receivable (A/R) for all inpatient admissions as there was a noticeable difference in the Case Mix Index from the year before. Upon initial observation, the CFO noted that there had been a dramatic increase in revenue for a particular DRG, which warranted an outside audit.

Scenario

Dr. Black is a primary care physician with admitting privileges to Davenport Hospital. The patient demographic of Dr. Blacks practice consists primarily of the elderly generation due to the popularity of his bedside manner and his willingness to see patients on the same day they request an appointment due to illness. Dr. Black has a reputation on the inpatient floors of the hospital for directly admitting his patients to the floor from his office on a regular basis and for his extensive diagnosis and treatment regimens.

Elsie Davis is a 64-year-old patient of Dr. Blacks who was directly admitted to Davenport Hospital with an initial diagnosis of difficulty breathing, rule out pneumonia. Dr. Black immediately ordered a chest x-ray on Elsie which showed lung inflammation indicating the presence of pneumonia. In addition to the chest x-ray, Dr. Black also ordered a blood culture on Elsie to aid in determining the type of pneumonia present.

On the second day of Elsies admission, after being on IV antibiotics for almost 24 hours and breathing treatments regularly, Elsie was still having difficulty breathing and catching her breath. On the Progress Note for Day 2, Dr. Black had added the diagnosis of Rule out Acute Respiratory Failure, which was a common practice for him.

On day 3 of the admission, the blood culture came back positive for Streptococcus Pneumoniae. Elsie continued to improve with the administration of IV antibiotics and was discharged at the end of Day 3 after being advised to quit smoking cigarettes and to follow up with Dr. Black in one week.

Dr. Black documented in his Discharge Summary that the final diagnosis was Pneumonia due to Streptococcus pneumoniae and Tobacco use.

Coding Synopsis

Below is a screenshot of the coding that was completed by Mary Smith, RHIT, Inpatient Coder for Davenport Hospital using the 3M Encoder.

3M Coding and Reimburseme... X VlaunchCRS html davenport.edu 3 Financing Connecting Yo Eile Options Reference Help CD-10 Summary Medicare DRG and MDC Information 20 193 SIMPLEIPNEUMONIA & PLEURISY W MCC CMS wt 1.4261 AlLOS 5.8 GLOS 4.8 Length of stay, discharge to a post-acute care provider, and home health service condition codes can significantly impact reimbursement for this DRG. 004 DISEASES & DISORDERS 0F THE RESPIRATORY SYSTEM Estimated Reimbursement-Medicare Inpatient Total: $0.00 Status: Inlier APR (all versions) DRG and MDC Information 25 139 OTHER PNEUMONIA APRwt 0.9394 Low Trim 1 High Trim 16 ALOS 5.34 GLOS 4.51 Status: LOS Inlier 004 RESPIRATORY SYSTEM 3 Major Severity of Illness 3 Major Risk of Mortality Admit Diagnosis RO64 Hyperventilation lt Principal Diagnosis 'J13 Pneumonia due to Streptococcus pneumoniae Secondary Diagnoses J96000 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia Z720 Tobacco use Search Home,Sercarett) Female, 56 Add Admit Dx Add Diagnosis Add Procedure Codeb00 Direct Code Compute DRG Options Analyze Next Patient