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Copyright/Disclaimer text

Determining MS-DRGsKimberly Cunningham CPC, CIC, CCS

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without the expressed written permission of AAPC.

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• MS-DRG

• Common Inpatient Conditions

• Transition from ICD-9 to ICD-10

• Case Review: Impact of ICD-10 on MS-DRG Determination

• Achieve DRG Accuracy

• Changes for 2017

Determining MS-DRGs

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MS-DRG

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• Medicare Severity – Diagnosis Related Grouping

• Relates the type of patients a hospital treats, or the case mix, with the cost to treat

those groups of patients

• Final ICD-10 MS DRG v33 was implemented October 1, 2015

• 25 Major Diagnostic Categories (MDC)

• Currently 758 total MS-DRGs

• Each MDC is divided into medical and surgical categories

• Medical categories are defined by the principal diagnosis

• Surgical categories are defined by a surgical/operating room procedure being

performed

MS-DRG

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• Steps to DRG assignment

• Determine the Principal Diagnosis

• Determine the Principal Procedure

• Identify and secondary conditions in accordance with the Uniform Hospital

Discharge Data Set (UHDDS)

• Determine if any secondary conditions are classified as MCC or CC diagnoses

• Also impact reimbursement:

• Discharge Disposition

• Patient age

• Patient gender

MS-DRG Determination

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Common Inpatient Conditions

• Congestive Heart Failure

• Renal Failure

• Infections

• Diabetes with or without complications

• Respiratory conditions – respiratory failure/COPD/pneumonia

• Anemia

• Malignancy

• Sepsis

• Obstetrics

Common Inpatient Conditions

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CMS Prevalence of Chronic Conditions

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• Congestive heart failure is the leading cause for admissions of adults 65 years

of age and older

• > 1 million admissions annually with CHF as the principal diagnosis

• In 2012 accounted for $17 billion in Medicare expenditures

• Most common comorbid conditions with CHF are hypertension and

hyperlipidemia

Congestive Heart Failure

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• 26 million adults in the US have CKD

• Heart disease is the leading cause of death for people with CKD

• Hypertension causes CKD and CKD causes hypertension

• High risk groups: diabetes, hypertension, family history of CKD

Renal Failure/Chronic Kidney Disease

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• Number of discharges with diabetes as first-listed diagnosis: 635,000

• Percent of adults 20 years and older with diabetes (physician-diagnosed or

undiagnosed): 12.3% (2009-2012)

• Percent of adults 20 years and older with physician-diagnosed diabetes: 8.9%

(2009-2012)

• Percent of adults 20 years and older with undiagnosed diabetes: 3.5% (2009-

2012)

• Average length of stay: 4.6 days

• Inpatient admission of diabetic patients is usually for treatment of a diabetic

complication

• Many complications require complicated treatment, surgical procedures and

diagnostic testing

Diabetes with and without complications

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• Septicemia is the most expensive condition treated in US hospitals

• Accounts for 5% of all hospitalizations in the United States

• 85% of patients with sepsis are admitted with the infection, the remainder acquire the condition

as an inpatient

• Overall Inpatient death rate of 17.2% of those admitted with Sepsis

• Death rate climbs in those with hospital acquired sepsis

• 38.6% for medical admissions

• 29.2% for surgical cases

• Sepsis is more costly to treat in academic facilities

Sepsis

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• Urinary Tract Infections

• Mainly older, male patient population

• Clostridium difficile Infection (C. diff)

• Most common HAI

• Recent trend of becoming a community acquired conditions – generally in a lower aged

population than those previously treated

• Pneumonia

• 1.1 million inpatient discharges for pneumonia in 2015

• Average length of stay is 5.2 days

• Cellulitis

• 15th most common inpatient condition

• Failure of resolution of symptoms is the number 1 reason for readmission to the hospital

within 30 days of initial admission with cellulitis

• Many diseases mimic cellulitis symptoms making diagnosis and treatment difficult

Infections

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• Hospital Acquired Conditions (HAC) or Hospital Inquired Infections (HAI)

• CMS publishes the list of HACs in the Final Rule

• Range from post operative complications and infections, to pressure ulcers and

injuries as a result of an inpatient fall

• CMS introduced a program in 2015 to reduce payment to facilities in an effort to

reduce HACs, Hospital Acquired Condition Reduction Program (HACRP)

Hospital Acquired Conditions

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Transition from ICD-9 to ICD-10

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Differences between ICD-9 to ICD-10

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Figure 1. Key differences between ICD-9-CM and ICD-10-CM and ICD-10-PCS code sets.Content source: CDC/National Center for Health Statistics

2017 Code

updates:

ICD-10-CM:

~1,928 new

diagnosis codes

ICD-10-PCS:

~3,651 new

procedure codes

• ICD-9 to ICD-10 conversion - mapping is not code to code

• Some code information does not exist in from ICD-9 to ICD-10 (i.e. laterality,

combination codes etc.

• Often ICD-9 codes need to be mapped to an ICD-10 code and then “backward”

mapped back to ICD-9 to determine the equivalent code

• Loss of code accuracy with mapping, only accurate 5% of the time

GEMS (General Equivalence Mappings)

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• When the MS-DRG assignment for a record coded in ICD-9 differs from that of

the same record coded in ICD-10.

DRG Shift

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• In ICD-10-CM there are some codes that act as their own MCC or CC

• These codes were conditions generally defined by two separate codes in ICD-9-

CM

• CMS has composed a list that indicates which codes act as their own MCC and

CCs in the Final Rule

MCCs and CCs as own Principal Diagnosis

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Condition ICD-9-CM ICD-10-CM

Candidal Sepsis (MCC) 112.5, 995.91 B37.7

Whooping cough due to

Bordetella pertussis

w/pneumonia (MCC)

033.8, 484.3 A37.01

Pressure ulcer of left hip, stage

3 (MCC)

707.04, 707.23 L89.223

Severe sepsis w/Septic Shock

(MCC)

038.9, 785.52, 995.92 R65.21

DM Type II w/PVD w/gangrene,

controlled (CC)

250.70, 443.81, 785.4 E11.52

CAD w/unstable angina (CC) 414.00, 411.1 I25.110

Crohn’s disease of colon

w/abscess (CC)

555.1, 569.5 K50.114

Sickle-cell thalassemia crisis

w/acute chest syndrome (CC)

282.42, 517.3 D57.411

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• Major comorbid/complications

• Pneumonia

• Acute systolic congestive heart failure

• Severe malnutrition

• Encephalopathy

• Comorbid/complications

• Acute kidney failure

• Cellulitis

• Acute exacerbation of chronic obstructive pulmonary disease

• Acute Blood Loss Anemia

MCC and CC

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• Three Services Negatively Impacted by DRG shifts

• General Surgery

• General Medicine

• Cardiac Services

• Facility impact depends on case mix, and proportion or medical cases in relation

to surgical cases

Revenue Declines

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MS-DRG Description Positive Shift %

766 Cesarean Section W/O CC/MCC 2%

792 Prematurity W/O Major Problems 5%

192 Chronic Obstructive Pulmonary Disease W/O CC/MCC 10%

310 Cardiac Arrhythmia and Conduction Disorders W/O MCC/CC 3%

195 Simple Pneumonia and Pleurisy 5%

Top 5 DRG upshifts

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https://www.advisory.com/research/financialleadershipcouncil/atthemargins/2015/06/thegoodandbadnewswithseveritytierccmccchangesinicd10

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• Case Review

• Impact of ICD-10 on MS-DRG Determination• Cases reviewed by WEDI ICD-10 Clinical Workgroup

MSSA Lung Infection

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• Pyothorax without fistula

• ICD-9-CM 510.9

• ICD-10-CM J86.9

• GEM backward maps to code 511.0 which would result in lower DRG relative weight and

payment

MSSA Lung Infection

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Obstetrics

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• ICD-9 Coding

• 64231 Transient hypertension of pregnancy, delivered , with or without mention of antepartum

condition

• 7359 Other manually assisted delivery

• 7562 Repair of current obstetric laceration of rectum and sphincter ani

• ICD-10 Coding

• O133 Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester

• 10E0XZZ Delivery of Products of Conception, External Approach

• 0DQR0ZZ Repair Anal Sphincter, Open Approach

• 0DQP0ZZ Repair Rectum, Open Approach

• In the case coded in ICD-9, the procedure codes relate to an obstetric diagnosis where in the

ICD-10 coding, the procedure coding does not reflect any obstetric diagnosis information and

correlates to a surgical procedure and generates a higher reimbursement.

Obstetrics

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Revision of Knee Replacement

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• ICD-9 Proc 0082 Revision of knee replacement, femoral component

• ICD-10-PCS 0SPC0JZ Removal of Synthetic Substitute from Right

Knee Joint, Open Approach

• ICD-10-PCS 0SRT0J9 Replacement of Right Knee Joint, Femoral

Surface with Synthetic Substitute, Cemented, Open Approach

• ICD-10-PCS 0SWC0JZ Revision of Synthetic Substitute in R Knee Jt,

Open Approach

Revision of Knee Replacement

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Sepsis

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• Candidal Sepsis B37.7 is included on the CC excludes list, so when coded with

another sepsis code it is no longer a CC condition

• Backward mapping of Candidal sepsis provides the additional MCC

• Sepsis 995.91 - MCC

Sepsis

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Hypertension

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• Malignant hypertension – 401.0 was a CC in ICD-9-CM

• GEM directs coder to code I10 as the equivalent code for Malignant

hypertension in ICD-10-CM

• I10 is not a CC diagnosis

Hypertension

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Diabetes Mellitus with Hyperosmolarity with Hyperglycemia

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Diabetes Mellitus w/Hyperosmolarity and Hyperglycemia

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• ICD-9-CM code 250.22 - Diabetes with hyperosmolarity, type II or unspecified

type, uncontrolled maps to 2 ICD-10-CM codes

• Proper sequencing of E11.65 as the principal diagnosis results in lower weighted

DRG

Pacemaker Insertion

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• Procedure coding in ICD-9-CM is related to diagnosis coding and impacts DRG

assignment

• Procedure coding in ICD-10-PCS has no impact on DRG assignment

• Native coding translates to lower weighted DRG when coded in ICD-10-CM and

PCS code sets

• Majority of PCS code set changes for October 1, 2016 will be in the cardiac

section

Pacemaker Insertion

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PTCA

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• DRG assignment for ICD-9 procedure codes equated having 4 or more stents

and/or an MCC condition as qualifying for the same DRG weight

• ICD-10-PCS currently does not account for the number of stents or vessels that

are treated

• Changes to the ICD-10-PCS code set on October 1, 2016 will address the

number of stents and arteries treated for percutaneous procedures

PTCA

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Achieve DRG Accuracy

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• Clinical Documentation

• Physician training on ICD-10 coding concepts and guidelines

• Educational materials for physicians on proper documentation

• Ensure EMR facilitates proper documentation

• Code Selection

• Ensure proper code selection in accordance with ICD-10 coding concepts and

guidelines

• Educational materials for coders on code revisions, deletions and additions

• Data Analytics

• Review the data

• Conduct audits

Achieve DRG Accuracy

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Changes for 2017

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• CM changes

• 1,928 new diagnosis codes

• New codes and code revisions provide more code specificity

• Laterality added for additional codes that do not currently have that designation

• PCS changes

• 3,651 new procedure codes

• Mainly updates to the cardiac procedure codes for bypass procedures and PTCA

procedures

Code changes for 2017

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Questions?

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• American Heart Association – Akshay S. Desai, MD, MPH; Lynne W. Stevenson, MD 2012

• http://circ.ahajournals.org/content/126/4/501.full

• CMS/Chronic conditions

• https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/CC_Main.html Page last Modified: 01/07/2016 2:10 PM

• National Kidney Foundation

• https://www.kidney.org/kidneydisease/aboutckd

• Centers for Disease Control and Prevention

• http://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm

• Outcomes and Resource Use of Sepsis-associated Stays by Presence on Admission, Severity, and Hospital Type

• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4751740/

• World J Urol. 2014 Jun;32(3):813-9. doi: 10.1007/s00345-013-1167-3. Epub 2013 Sep 27.

• Predictors of admission in patients presenting to the emergency department with urinary tract infection.

• http://www.ncbi.nlm.nih.gov/pubmed/24072010

• Community-acquired Clostridium difficile infection: an increasing public health threat

• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3962320/

• Pneumonia Fastats

• http://www.cdc.gov/nchs/fastats/pneumonia.htm

• THE GROWING PROBLEM OF PSEUDOCELLULITIS

• http://www.consultant360.com/articles/growing-problem-pseudocellulitis

• Hospital-Acquired Condition Reduction Program (HACRP)

• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program.html

• Diabetes Fastsats

• http://www.cdc.gov/nchs/fastats/diabetes.htm

• Management of diabetes mellitus in hospitalized patients

• http://www.uptodate.com/contents/management-of-diabetes-mellitus-in-hospitalized-patients

• CMS ICD10 tool kit

• https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10NextStepsToolkit20160226.pdf

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References: