Sample page. DRG Desk Reference. The ultimate resource for improving MS-DRG assignment practices DESK REFERENCE
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1 DESK REFERENCE 2018 DRG Desk Reference The ultimate resource for improving MS-DRG assignment practices POWER UP YOUR CODING with Optum360, your trusted coding partner for 32 years. Visit optum360coding.com.
2 Contents Contents Introduction...1 Basic Steps of Accurate DRG Assignment...1 DRG History...1 Reasons for Moving to Severity-Adjusted DRGs...2 Development of MS-DRGs...2 Comprehensive Review of CC List...3 Basic Characteristics of MS-DRG Classification...4 MS-DRG Assignment Process...7 Government Scrutiny...8 Keys to a Financially Successful DRG Program...9 Instructions for Using Your DRG Desk Reference Introduction...11 Pre MDC...11 Diseases And Disorders Of The Nervous System...15 Diseases And Disorders Of The Eye Diseases And Disorders Of The Ear, Nose, Mouth And Throat Diseases And Disorders Of The Respiratory System Diseases And Disorders Of The Circulatory System Diseases And Disorders Of The Digestive System Diseases And Disorders Of The Hepatobiliary System And Pancreas Diseases And Disorders Of The Musculoskeletal System And Connective Tissue Diseases And Disorders Of The Skin, Subcutaneous Tissue And Breast Endocrine, Nutritional And Metabolic Diseases And Disorders Diseases And Disorders Of The Kidney And Urinary Tract Diseases And Disorders Of The Male Reproductive System Diseases And Disorders Of The Female Reproductive System Pregnancy, Childbirth And The Puerperium Newborns And Other Neonates With Conditions Originating In The Perinatal Period Diseases And Disorders Of The Blood And Blood-Forming Organs And Immunological Disorders Myeloproliferative Diseases And Disorders And Poorly Differentiated Neoplasms Infectious And Parasitic Diseases, Systemic or Unspecified Sites Mental Diseases And Disorders Alcohol/Drug Use And Alcohol/Drug-Induced Organic Mental Disorders Injuries, Poisonings And Toxic Effects Of Drugs Burns Factors Influencing Health Status And Other Contacts With Health Services Multiple Significant Trauma Human Immunodeficiency Virus Infections ALL MDCs DRG List Numeric Lists of CCs and MCCs Numeric CC List Numeric MCC List Lists of Principal Diagnoses That Are Their Own CC and Their Own MCC Principal Diagnoses That Are Their Own CC Principal Diagnoses That Are Their Own MCC Neonate Major Problems (Principal or Secondary Diagnosis) Neonate Other Significant Problems (Principal or Secondary Diagnosis) Glossary Optum360, LLC iii
3 MDC 5 Diseases And Disorders Of The Circulatory SystemMDC 5 DRG 215 Other Heart Assist System Implant RW Heart Transplant or Implant of Heart Assist System with MCC Insertion of implantable heart assist system 02HA[0,3,4]QZ Review operative report carefully to determine extent of all or implantation of total internal biventricular heart replacement system procedures. Implantable ventricular assist devices are attached to the native heart. A total artificial heart (TAH) is an implantable biventricular support device that serves as a total replacement for both ventricles of the failing heart. Insertion of external heart assist system 02HA[0,4]R[S,Z] Both codes must be reported. Review operative report with removal of existing heart assist system 02HA3RS carefully to determine extent of all procedures. External (e.g. replacement, exchange) (sometimes called Percutaneous ventricular assist devices 02PA[0,3,4]RZ (pvads) are generally placed through the femoral artery via catheter. Both insertion and removal must be performed. Removal and revision of heart assist system 02WA[0,3,4][Q,R]Z 02PA[0,3,4]RZ Both codes must be reported. Root operation "Revision" is correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced device. Removal must be performed in conjunction with revision. DRG 216 Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac RW Catheterization with MCC No DRG 217 Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with CC RW MCC Condition DRG 218 Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization without CC/MCC RW Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with CC MCC Condition 217 CC Condition See CC section DRG 219 Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac RW Catheterization with MCC 216 Cardiac catheterization (right, left, bilateral) for measurement of cardiac sampling and pressure, or with angiocardiography (coronary angiography) Catheter based invasive cardiac electrophysiology study 4A02[0,3]N6 4A02[0,3]N7 4A02[0,3]N8 B20* B210[0,1,Y]ZZ B211[0,1,Y]ZZ B212[0,1,Y]ZZ 4A023FZ B213[0,1,Y]ZZ B214* B215* B216* B217* B218* B21F* 2017 Optum360, LLC * Code Range 175
4 DRG 243 (Continued) MDC Pacemaker device replacement - insertion with removal of old device 0JH6[0,3][0,7,P]Z 0JH8[0,3][0,7,P]Z Review record for pacemaker replacement procedure. Two codes must be reported - both removal and insertion. 260 Cardiac pacemaker revision procedure 0JWT0PZ 0JWT3PZ Root operation Revision is defined as: Correcting, to the extent possible, a malfunctioning or displaced device and is coded when the objective of the procedure is to correct the position or function of a previously placed device, without taking the entire device out and putting in a whole new device in its place. Revision can include correcting a malfunctioning device by taking out and/or putting in part, but not all, of the device. Example of pacemaker revision would be adjustment of the position of pacemaker lead without removing or replacing the lead. DRG 244 Permanent Cardiac Pacemaker Implant without CC/MCC RW Cardiac Defibrillator Implant with Cardiac Catheterization with Acute Myocardial Infarction/Heart Failure/Shock with MCC Cardiac Defibrillator Implant with Cardiac Catheterization with Acute Myocardial Infarction/Heart Failure/Shock without MCC Cardiac Defibrillator Implant with Cardiac Catheterization without Acute Myocardial Infarction/Heart Failure/Shock with MCC Cardiac Defibrillator Implant with Cardiac Catheterization without Acute Myocardial Infarction/Heart Failure/Shock without MCC Cardiac Defibrillator Implant without Cardiac Catheterization with MCC Cardiac Defibrillator Implant without Cardiac Catheterization without MCC Permanent Cardiac Pacemaker Implant with MCC Permanent Cardiac Pacemaker Implant with CC Cardiac defibrillator implant 0JH[6,8][0,3]8Z 02H4[0,4]KZ 02HN[0,3,4][J,K,M]Z Two codes must be reported - both the generator and lead(s) are inserted. 0JH[6,8][0,3]9Z 02H[4,6,7][0,3,4]KZ 02H43[J,K,M]Z 02HN[0,3,4][J,K,M]Z 02H[6,7,K][0,3,4]KZ 0JH[6,8][0,3]8Z 02HL[0,3,4]KZ 0JH[6,8][0,3][8,9]Z 02HL[0,3,4]MZ 0JH[6,8][0,3]AZ Hypertensive heart and kidney disease with I11.0 heart failure I13.0 I13.2 Acute myocardial infarction, initial episode II21.01 I21.21 I22.1 A code from category I22, Subsequent MI, is of care I21.02 I21.29 I22.2 reported when a patient who has suffered an AMI I21.09 I21.3 I22.8 has a new AMI within the 4 week time frame of the I21.11 I21.4 I22.9 initial AMI. A code from category I22 must be used I21.19 I22.0 in conjunction with a code from category I21. Sequencing of these codes depends on the circumstances of the encounter. Heart failure, all types I50.1 I50.20 I50.21 I50.22 I50.23 Shock, cardiogenic or unspecified R57.0 R57.9 Cardiac catheterization (right, left, bilateral) for measurement of cardiac sampling and pressure, or with angiocardiography (coronary angiography) 4A02[0,3]N6 4A02[0,3]N7 4A02[0,3]N8 B20* B210[0,1,Y]ZZ I50.30 I50.31 I50.32 I50.33 I50.40 B211[0,1,Y]ZZ B212[0,1,Y]ZZ B213[0,1,Y]ZZ B214* B215* I50.41 I50.42 I50.43 I50.9 B216* B217* B218* B21F* Code first underlying cause Optum360, LLC * Code Range 213
5 2017 Optum360, LLC 781 Numeric Lists of CCs and MCCs Numeric Lists of CCs and MCCs Numeric CC List A00.0 A00.1 A00.9 A01.00 A01.01 A01.02 A01.03 A01.04 A01.05 A01.09 A01.1 A01.2 A01.3 A01.4 A02.0 A02.23 A02.24 A02.25 A02.29 A02.8 A02.9 A03.0 A04.0 A04.1 A04.2 A04.3 A04.4 A04.5 A04.6 A04.7 A04.8 A04.9 A05.0 A05.1 A05.2 A05.3 A05.4 A05.5 A05.8 A06.0 A06.1 A06.2 A06.3 A06.81 A06.82 A06.89 A07.1 A07.2 A07.3 A07.4 A07.8 A07.9 A08.0 A08.11 A08.19 A08.2 A08.31 A08.32 A08.39 A09 A15.0 A15.4 A15.5 A15.6 A15.7 A15.8 A15.9 A17.9 A18.01 A18.02 A18.03 A18.09 A18.10 A18.11 A18.12 A18.13 A18.14 A18.15 A18.16 A18.17 A18.18 A18.2 A18.32 A18.39 A18.4 A18.50 A18.51 A18.52 A18.53 A18.54 A18.59 A18.6 A18.7 A18.81 A18.82 A18.83 A18.84 A18.85 A18.89 A21.0 A21.1 A21.2 A21.3 A21.7 A21.8 A21.9 A22.0 A22.2 A22.8 A22.9 A23.8 A23.9 A24.0 A24.1 A24.2 A24.3 A24.9 A25.0 A25.1 A25.9 A27.0 A27.89 A27.9 A28.0 A28.1 A28.2 A28.8 A28.9 A30.0 A30.1 A30.2 A30.3 A30.4 A30.5 A30.8 A30.9 A31.0 A31.1 A31.2 A31.8 A31.9 A32.0 A32.11 A32.12 A32.81 A32.82 A32.89 A32.9 A34 A36.0 A36.1 A36.2 A36.3 A36.81 A36.82 A36.83 A36.84 A36.85 A36.86 A36.89 A36.9 A37.00 A37.10 A37.80 A37.90 A38.0 A38.1 A38.8 A38.9 A39.82 A39.83 A39.84 A39.89 A39.9 A42.0 A42.1 A42.2 A42.81 A42.82 A42.89 A42.9 A43.0 A43.1 A43.8 A43.9 A44.0 A44.1 A44.8 A44.9 A48.51 A48.52 A50.01 A50.02 A50.03 A50.04 A50.05 A50.06 A50.07 A50.08 A50.09 A50.2 A50.30 A50.31 A50.32 A50.39 A50.40 A50.43 A50.44 A50.45 A50.49 A50.51 A50.52 A50.53 A50.54 A50.55 A50.56 A50.57 A50.59 A51.31 A51.32 A51.39 A51.42 A51.43 A51.44 A51.45 A51.46 A51.49 A52.00 A52.01 A52.02 A52.03 A52.04 A52.05 A52.06 A52.09 A52.10 A52.11 A52.12 A52.15 A52.16 A52.17 A52.19 A52.2 A52.3 A52.71 A52.72 A52.73 A52.74 A52.75 A52.76 A52.77 A52.78 A52.79 A54.00 A54.01 A54.02 A54.03 A54.09 A54.1 A54.21 A54.22 A54.23 A54.24 A54.29 A54.30 A54.31 A54.32 A54.33 A54.39 A54.40 A54.41 A54.42 A54.43 A54.49 A54.82 A54.83 A54.84 A54.85 A54.89 A54.9 A68.0 A68.1 A68.9 A69.1 A69.20 A69.21 A69.22 A69.23 A69.29 A70 A75.0 A75.1 A75.2 A75.3 A75.9 A77.0 A77.1 A77.2 A77.3 A77.40 A77.41 A77.49 A77.8 A77.9 A78 A79.0 A79.1 A79.81 A79.89 A79.9 A81.00 A81.01 A81.09 A81.1 A81.2 A81.81 A81.82 A81.83 A81.89 A81.9 A82.0 A82.1 A82.9 A85.0 A85.1 A85.8 A86 A87.0 A87.1 A87.2 A87.8 A87.9 A88.0 A88.8 A89 A90 A91 A92.0 A92.1 A92.2 A92.4 A92.8 A92.9 A93.0 A93.1 A93.2 A93.8 A94 A95.0 A95.1 A95.9 A96.0 A96.1 A96.8 A96.9 A98.0 A98.1 A98.2 A98.5 A98.8 A99 B00.2 B00.50 B00.51 B00.52 B00.53 B00.59 B00.81 B00.89 B01.0 B01.81 B01.89 B01.9 B02.0 B02.21 B02.22 B02.23 B02.29 B02.30 B02.31 B02.32 B02.33 B02.34 B02.39 B02.7 B02.8 B03 B04 B05.1 B05.4 B05.81 B05.89 B06.00 B06.02 B06.09 B06.81 B06.82 B06.89 B08.3 B08.71 B15.9 B16.1 B16.9 B17.0 B17.10 B17.2 B17.8 B17.9 B18.0 B18.1 B18.8 B18.9 B19.10 B19.9 B25.1 B25.8 B25.9 B26.0 B26.3 B26.81 B26.82 B26.83 B26.84 B26.85 B26.89 B33.1 B33.20 B33.21 B33.22 B33.23 B33.4 B34.3 B37.0 B37.41 B37.49 B37.81 B37.82 B37.83 B37.84 B37.89 B38.0 B38.1 B38.2 B38.3 B38.7 B38.81 B38.89 B38.9 B39.3 B40.0 B40.1 B40.2 B40.3 B40.7 B40.81 B40.89 B40.9 B41.0 B41.7 B41.8 B41.9 B44.1 B44.2 B44.7 B44.81 B44.89 B44.9 B45.0 B45.2 B45.3 B45.7 B45.8 B45.9 B47.0 B47.1 B47.9 B48.2 B48.3 B48.4 B48.8 B49 B50.0 B50.8 B51.0 B51.8 B51.9 B52.0 B52.8 B52.9 B53.0 B53.1 B53.8 B54 B55.0 B55.1 B55.2 B55.9 B56.0 B56.1 B56.9 B57.0 B57.1 B57.2 B57.30 B57.31 B57.32 B57.39 B57.40 B57.41 B57.42 B57.49 B57.5 B58.00
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