DRG Expert. A comprehensive guidebook to the MS-DRG classification system. Changes effective with discharges on or after October 1, 2015.

Transcription

1 DRG Expert A comprehensive guidebook to the MS-DRG classification system Changes effective with discharges on or after October 1, nd Edition

2 Contents Numeric Listing of DRGs... i DRG Listing by Major Diagnostic Category... xi Introduction... xxi DRGs Pre MDC... 1 MDC 1 Diseases And Disorders Of The Nervous System... 5 MDC 2 Diseases And Disorders Of The Eye...35 MDC 3 Diseases And Disorders Of The Ear, Nose, Mouth And Throat...41 MDC 4 Diseases And Disorders Of The Respiratory System...49 MDC 5 Diseases And Disorders Of The Circulatory System...55 MDC 6 Diseases And Disorders Of The Digestive System...70 MDC 7 Diseases And Disorders Of The Hepatobiliary System And Pancreas...80 MDC 8 Diseases And Disorders Of The Musculoskeletal System And Connective Tissue...84 MDC 9 Diseases And Disorders Of The Skin, Subcutaneous Tissue And Breast MDC 10 Endocrine, Nutritional And Metabolic Diseases And Disorders MDC 11 Diseases And Disorders Of The Kidney And Urinary Tract MDC 12 Diseases And Disorders Of The Male Reproductive System MDC 13 Diseases And Disorders Of The Female Reproductive System MDC 14 Pregnancy, Childbirth And The Puerperium MDC 15 Newborns And Other Neonates With Conditions Originating In The Perinatal Period MDC 16 Diseases And Disorders Of The Blood And Blood-Forming Organs And Immunological Disorders MDC 17 Myeloproliferative Diseases And Disorders And Poorly Differentiated Neoplasms MDC 18 Infectious And Parasitic Diseases, Systemic or Unspecified Sites MDC 19 Mental Diseases And Disorders MDC 20 Alcohol/Drug Use And Alcohol/Drug- Induced Organic Mental Disorders MDC 21 Injuries, Poisonings And Toxic Effects Of Drugs MDC 22 Burns MDC 23 Factors Influencing Health Status And Other Contacts With Health Services MDC 24 Multiple Significant Trauma MDC 25 Human Immunodeficiency Virus Infections DRGs Associated with All MDCs Alphabetic Index to Diseases Numeric Index to Diseases Alphabetic Index to Procedures Numeric Index to Procedures Appendix A Lists of CCs and MCCs Appendix B MS-DRG Surgical Hierarchy Table Appendix C MS-LTC-DRG Crosswalk Appendix D National Average Payment Table Appendix E 2013 MedPAR National Data Appendix F Medicare Case Mix Index Data Glossary of DRG Terms...621

3 Diseases And Disorders Of The Circulatory System MDC 5 DRG 223 DRG Cardiogenic shock Operating Room Procedures Implantation of cardiac resynchronization defibrillator, total system (CRT-D) Implantation of rechargeable cardiac contractility modulation [CCM], total system Implantation or replacement of automatic cardioverter/ defibrillator, total system (AICD) Any of the following procedure combinations Implantation or replacement of transvenous lead (electrode) into left ventricular coronary venous system Replacement of automatic cardioverter/defibrillator pulse Implantation of automatic cardioverter/defibrillator leads(s) Implantation of automatic cardioverter/defibrillator leads(s) Replacement of automatic cardioverter/defibrillator leads(s) Replacement of automatic cardioverter/defibrillator leads(s) Replacement of automatic cardioverter/defibrillator pulse Nonoperating Room Procedures Right heart cardiac catheterization Left heart cardiac catheterization Combined right and left heart cardiac catheterization Angiocardiography of right heart structures Angiocardiography of left heart structures Combined right and left heart angiocardiography Coronary arteriography using single catheter Coronary arteriography using two catheters Other and unspecified coronary arteriography Negative-contrast cardiac roentgenography DRG 223 with Acute Myocardial Infarction/Heart Failure/Shock without MCC GMLOS 4.4 AMLOS 6.0 RW Select principal diagnosis operating room procedure procedure combinations nonoperating room procedure listed under DRG 222 DRG 224 without Acute Myocardial Infarction/Heart Failure/Shock with MCC GMLOS 7.9 AMLOS 9.8 RW Select any principal diagnosis listed under MDC 5 excluding acute myocardial infarction, heart failure and shock Select any operating room procedure procedure combination nonoperating room procedure listed under DRG 222 DRG 225 without Acute Myocardial Infarction/Heart Failure/Shock without MCC GMLOS 4.1 AMLOS 4.9 RW Select any principal diagnosis listed under MDC 5 excluding acute myocardial infarction, heart failure and shock Select any operating room procedure procedure combination nonoperating room procedure listed under DRG 222 DRG 226 Cardiac Defibrillator Implant without Cardiac Catheterization with MCC GMLOS 6.3 AMLOS 8.7 RW Operating Room Procedures Implantation of cardiac resynchronization defibrillator, total system (CRT-D) Implantation of rechargeable cardiac contractility modulation [CCM], total system Implantation or replacement of automatic cardioverter/ defibrillator, total system (AICD) Any of the following procedure combinations Implantation or replacement of transvenous lead (electrode) into left ventricular coronary venous system MDC 5: Diseases And Disorders Of The Circulatory System SURGICAL Surgical Medical CC Indicator MCC Indicator Procedure Proxy 2015 Optum360, LLC Valid 10/01/ /30/

4 Alphabetic Index to Diseases completed weeks of gestation completed weeks of gestation completed weeks of gestation 163, completed weeks of gestation 163, completed weeks of gestation 163, completed weeks of gestation 163, completed weeks of gestation 163, or more completed weeks of gestation 171, Abdominal actinomycotic infection Abdominal aneurysm without mention of rupture Abdominal aneurysm, ruptured Abdominal aorta injury 166, * Abdominal or pelvic swelling, mass, or lump * Abdominal pain * Abdominal rigidity * Abdominal tenderness Abnormal chest sounds * Abnormal cytologic smear of anus and anal HPV Abnormal finding on antenatal screening 156, * Abnormal glucose Abnormal innervation syndrome of eyelid Abnormal involuntary movements * Abnormal loss of weight Abnormal maternal glucose tolerance complicating pregnancy, childbirth, or the puerperium, postpartum condition or complication Abnormal maternal glucose tolerance, antepartum 154, Abnormal maternal glucose tolerance, complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care Abnormal maternal glucose tolerance, with delivery 134, 142, Abnormal maternal glucose tolerance, with delivery, with current postpartum complication 135, 142, * Abnormal Papanicolaou smear of cervix and cervical HPV 127, * Abnormal Papanicolaou smear of vagina and vaginal HPV 127, Abnormal posture Abnormal reflex Abnormal sputum * Abnormal tumor markers Abnormality in fetal heart rate or rhythm, antepartum condition or complication 155, Abnormality in fetal heart rate or rhythm, delivered, with or without mention of antepartum condition 136, 143, Abnormality in fetal heart rate or rhythm, unspecified as to episode of care or not applicable 136, 143, Abnormality of gait * Abnormality of red blood cells Abnormality of secretion of gastrin Abnormality of secretion of glucagon * ABO incompatibility reaction due to transfusion of blood or blood products 167, 171, * Abortion, unspecified as to legality Abrasion or friction burn of finger, without mention of infection Abrasion or friction burn of foot and toe(s), without mention of infection Abrasion or friction burn of other, multiple, and unspecified sites, without mention of infection Abscess of anal and rectal regions 79, 166, Abscess of Bartholin s gland 127, Abscess of breast associated with childbirth, delivered, with mention of postpartum complication 139, 141, Abscess of breast associated with childbirth, delivered, with or without mention of antepartum condition 139, 141, Abscess of breast associated with childbirth, unspecified as to episode of care Abscess of breast, antepartum 156, Abscess of breast, postpartum condition or complication Abscess of intestine Abscess of liver 166, * Abscess of lung and mediastinum 51, 165, Abscess of thymus 164, * Acariasis Accidental puncture or laceration during procedure 167, 171, Acetonuria Achalasia and cardiospasm Achilles bursitis or tendinitis Achlorhydria Achromatopsia 39 V45.71 Acquired absence of breast and nipple 214 V88.0* Acquired absence of cervix and uterus 128, 131 V45.72 Acquired absence of intestine (large) (small) 214 V88.2* Acquired absence of joint 215 V45.73 Acquired absence of kidney 214 V45.78 Acquired absence of organ, eye 40 V45.77 Acquired absence of organ, genital organs 124, 128, 131 V45.76 Acquired absence of organ, lung 54 V45.74 Acquired absence of organ, other parts of urinary tract 120 V45.75 Acquired absence of organ, stomach 214 V88.1* Acquired absence of pancreas Acquired auditory processing disorder Acquired cardiac septal defect Acquired coagulation factor deficiency Acquired color vision deficiencies Acquired cyst of kidney * Acquired deformities of hip * Acquired deformities of other parts of limbs * Acquired deformities of toe Acquired deformity of chest and rib Acquired deformity of limb, site unspecified Acquired deformity of neck Acquired deformity of nose Acquired deformity of pelvis Acquired equinovarus deformity Acquired hemolytic anemia, unspecified 164, 169, * Acquired hemolytic anemias Acquired hemophilia Acquired hypertrophic pyloric stenosis * Acquired hypothyroidism 114 Alphabetic Index to Diseases 2015 Optum360, LLC *Code Range 237

5 Appendix D National Average Payment Table The national average payment for each DRG is calculated by multiplying the current relative weight of the DRG by the national average hospital Medicare base rate. The national average hospital Medicare base rate is the average of the sum of the full update labor-related and nonlabor-related amounts published in the Federal Register, FY 2015 Correction Notice, Table 1A. National Adjusted Operating Standardized Amounts; Labor/Nonlabor (if wage index greater than 1) or Table 1B. National Adjusted Operating Standardized Amounts; Labor/Nonlabor (if wage index less than or equal to 1). This information is provided as a benchmark reference. There is no official publication of the average hospital base rate; therefore the national average payments provided in this table are approximate. DRG Description GMLOS AMLOS Relative Weight National Payment Rate 001 HEART TRANSPLANT IMPLANT OF HEART ASSIST SYSTEM W MCC $137, HEART TRANSPLANT IMPLANT OF HEART ASSIST SYSTEM W/O MCC $84, T 003 ECMO TRACH W MV 96+ HRS PDX EXC FACE, MOUTH & NECK W MAJ O.R $95, T 004 TRACH W MV 96+ HRS PDX EXC FACE, MOUTH & NECK W/O MAJ O.R $58, LIVER TRANSPLANT W MCC INTESTINAL TRANSPLANT $56, LIVER TRANSPLANT W/O MCC $25, LUNG TRANSPLANT $50, SIMULTANEOUS PANCREAS/KIDNEY TRANSPLANT $28, PANCREAS TRANSPLANT $22, TRACHEOSTOMY F FACE,MOUTH & NECK DIAGNOSES W MCC $25, TRACHEOSTOMY F FACE,MOUTH & NECK DIAGNOSES W CC $17, TRACHEOSTOMY F FACE,MOUTH & NECK DIAGNOSES W/O CC/MCC $11, ALLOGENEIC BONE MARROW TRANSPLANT $59, AUTOLOGOUS BONE MARROW TRANSPLANT W CC/MCC $31, AUTOLOGOUS BONE MARROW TRANSPLANT W/O CC/MCC $22, INTRACRANIAL VASCULAR PROCEDURES W PDX HEMRHAGE W MCC $50, INTRACRANIAL VASCULAR PROCEDURES W PDX HEMRHAGE W CC $38, INTRACRANIAL VASCULAR PROCEDURES W PDX HEMRHAGE W/O CC/MCC $24, T 023 CRANIO W MAJ DEV IMPL/ACUTE COMPLEX CNS PDX W MCC CHEMO IMPLANT $28, T 024 CRANIO W MAJ DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC $20, T 025 CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC $23, T 026 CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC $16, T 027 CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC $12, t 028 SPINAL PROCEDURES W MCC $29, t 029 SPINAL PROCEDURES W CC SPINAL NEUROSTIMULATS $17, t 030 SPINAL PROCEDURES W/O CC/MCC $9, T 031 VENTRICULAR SHUNT PROCEDURES W MCC $22, T 032 VENTRICULAR SHUNT PROCEDURES W CC $10, T 033 VENTRICULAR SHUNT PROCEDURES W/O CC/MCC $8, CAROTID ARTERY STENT PROCEDURE W MCC $19, Calculated with an average hospital Medicare base rate of $5, Each hospital s base rate and corresponding payment will vary. The national average hospital Medicare base rate is the average of the sum of the full update labor-related and nonlabor-related amounts published in the Federal Register, FY 2015 Correction Notice, Table 1A. National Adjusted Operating Standardized Amounts; Labor/Nonlabor (if wage index greater than 1) or Table 1B. National Adjusted Operating Standardized Amounts; Labor/Nonlabor (if wage index less than or equal to 1). MS-DRGs 998 and 999 contain cases that could not be assigned to valid DRGs. Note: If there is no value in either the geometric mean length of stay or the arithmetic mean length of stay columns, the volume of cases is insufficient to determine a meaningful computation of these statistics. Appendix D National Average Payment Table 2015 Optum360, LLC T Transfer DRG t Special Payment 577