Determining MS-DRGs. Kimberly Cunningham CPC, CIC, CCS. Copyright/Disclaimer text

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1 Determining MS-DRGs Kimberly Cunningham CPC, CIC, CCS Copyright/Disclaimer text No part of this presentation may be reproduced or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording, or taping) without the expressed written permission of AAPC. 2 1

2 Determining MS-DRGs 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 MS-DRG 4 2

3 MS-DRG 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, 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 5 MS-DRG Determination 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 6 3

4 Common Inpatient Conditions 7 Common Inpatient Conditions Congestive Heart Failure Renal Failure Infections Diabetes with or without complications Respiratory conditions respiratory failure/copd/pneumonia Anemia Malignancy Sepsis Obstetrics 8 4

5 CMS Prevalence of Chronic Conditions 9 Congestive Heart Failure 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 10 5

6 Renal Failure/Chronic Kidney Disease 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 11 Diabetes with and without complications 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% ( ) Percent of adults 20 years and older with physician-diagnosed diabetes: 8.9% ( ) Percent of adults 20 years and older with undiagnosed diabetes: 3.5% ( ) 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 12 6

7 Sepsis 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 13 Infections 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 15 th 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 14 7

8 Hospital Acquired Conditions 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) 15 Transition from ICD-9 to ICD

9 Differences between ICD-9 to ICD Code updates: ICD-10-CM: ~1,928 new diagnosis codes ICD-10-PCS: ~3,651 new procedure codes 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 17 GEMS (General Equivalence Mappings) 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 18 9

10 DRG Shift When the MS-DRG assignment for a record coded in ICD-9 differs from that of the same record coded in ICD MCCs and CCs as own Principal Diagnosis 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 20 10

11 Condition ICD-9-CM ICD-10-CM Candidal Sepsis (MCC) 112.5, B37.7 Whooping cough due to Bordetella pertussis w/pneumonia (MCC) Pressure ulcer of left hip, stage 3 (MCC) 033.8, A , L Severe sepsis w/septic Shock (MCC) DM Type II w/pvd w/gangrene, controlled (CC) 038.9, , R , , E11.52 CAD w/unstable angina (CC) , I Crohn s disease of colon w/abscess (CC) 555.1, K Sickle-cell thalassemia crisis w/acute chest syndrome (CC) , D 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 22 11

12 Revenue Declines 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 23 Top 5 DRG upshifts 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%

13 Case Review Impact of ICD-10 on MS-DRG Determination Cases reviewed by WEDI ICD-10 Clinical Workgroup 25 MSSA Lung Infection 26 13

14 MSSA Lung Infection Pyothorax without fistula ICD-9-CM ICD-10-CM J86.9 GEM backward maps to code which would result in lower DRG relative weight and payment 27 Obstetrics 28 14

15 Obstetrics ICD-9 Coding 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. 29 Revision of Knee Replacement 30 15

16 Revision of Knee Replacement 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 31 Sepsis 32 16

17 Sepsis 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 MCC 33 Hypertension 34 17

18 Hypertension Malignant hypertension 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 35 Diabetes Mellitus with Hyperosmolarity with Hyperglycemia 36 18

19 Diabetes Mellitus w/hyperosmolarity and Hyperglycemia ICD-9-CM code 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 37 Pacemaker Insertion 38 19

20 Pacemaker Insertion 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 39 PTCA 40 20

21 PTCA 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 41 Achieve DRG Accuracy 42 21

22 Achieve DRG Accuracy 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 43 Changes for

23 Code changes for 2017 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 45 Questions? 46 23

24 References: American Heart Association Akshay S. Desai, MD, MPH; Lynne W. Stevenson, MD CMS/Chronic conditions Page last Modified: 01/07/2016 2:10 PM National Kidney Foundation Centers for Disease Control and Prevention Outcomes and Resource Use of Sepsis-associated Stays by Presence on Admission, Severity, and Hospital Type World J Urol Jun;32(3): doi: /s Epub 2013 Sep 27. Predictors of admission in patients presenting to the emergency department with urinary tract infection. Community-acquired Clostridium difficile infection: an increasing public health threat Pneumonia Fastats THE GROWING PROBLEM OF PSEUDOCELLULITIS Hospital-Acquired Condition Reduction Program (HACRP) Diabetes Fastsats Management of diabetes mellitus in hospitalized patients CMS ICD10 tool kit