Making Sense and Demystifying the Relationships

Transcription

1 Making Sense and Demystifying the Relationships Within the Grouper Debbie Mackaman, RHIA, CPCO, CCDS Regulatory Specialist HCPro, an H3.Group Brand of Simplify This is the Full Title of a Session Compliance LLC Middleton, MA Shannon McCall, RHIA, CCS, CCS P, CPC, CEMC, CRC, CCDS Director of HIM/Coding HCPro, an H3.Group Brand of Simplify Compliance LLC Middleton, MA 1

2 Learning Objectives At the completion of this educational activity, the learner will be able to: Understand how the selection and manipulation of diagnoses and procedures influence the MS DRG assignment Identify the numerous elements that impact reimbursement under the MS DRG system Apply basic grouping logic to real world case studies Recognize opportunities to improve revenue in an IPPS hospital 2

3 Back to the Future It s 1983 Postage stamp $ 0.20 Loaf of bread $ 0.66 Gallon of milk $ 1.89 Gallon of gas $ 1.25 Mid size car $ 6, Annual average household income $ 12, Mid size family house $105, And the top song was Every Breath You Take by The Police ( ( End_Hot_100_singles_of_1983) 3

4 Medicare Introduces a Major Payment Shift FY 1984 Inpatient Prospective Payment System (IPPS) Pre 1983 Per diem cost based payment > LOS directly impacted payment Efficiency was not profitable Diagnosis was informational Payment was a reward for hospitals who kept patients longer, ordered more tests, performed more procedures Other factors Physicians paid MPFS Post 1983 One payment for each discharge < LOS created incentives to be more efficient Considered to be at risk Diagnosis code driven Payment based on similar patient, similar resources for all patients at all hospitals Other factors Weighting, wages, teaching hospital, rural vs. urban Physicians continued to be paid MPFS 4

5 Evolution of IPPS Need for greater refinement of patient classifications FY 1983: 367 DRGs FY 2018: 754 MS DRGs 1979: ICD 9 CM 2015: ICD 10 CM/PCS FY 1984: under DRGs, there was only one level of severity based on secondary diagnoses (CC) FY 2008: under MS DRGs, there were three levels of severity based on secondary diagnoses: Major complication/comorbidity (MCC) Complication/comorbidity (CC) Non complication/comorbidity (non CC) 5

6 Evolution of IPPS Four additional factors that influence MS DRG assignment and payment Principal diagnosis Diagnosis established after study to be chiefly responsible for causing the patient s admission to the hospital Procedures performed Reported with ICD 10 PCS Gender and discharge status Transfer or post acute transfer Pre MDC MS DRG Certain transplant, ECMO, and tracheostomy cases are preassigned to its highest paying DRG 6

7 Evolution of the Grouper 7

8 General Steps in Assigning MS DRGs DRG Assignment Only Diagnoses Diagnoses and Procedures THANK GOODNESS FOR GROUPERS! Numeric Index to Diseases; Age? Procedure Not Listed Numeric Index to Procedures CC/MCC? Determine MDC for PDx CC/MCC? 8

9 MS DRGs Major Diagnostic Categories MDC 1 Nervous System MDC 2 Eye MDC 3 Ear, Nose, Mouth & Throat MDC 4 Respiratory MDC 5 Circulatory MDC 6 Digestive MDC 7 Hepatobiliary System & Pancreas MDC 8 Musculoskeletal & Connective MDC 9 Skin, Subcu and Breast MDC 10 Endocrine, Nutritional & Metabolic MDC 11 Kidney & Urinary MDC 12 Male Reproductive MDC 13 Female Reproductive MDC 14 Pregnancy, Childbirth, Reproductive MDC 15 Newborns & Perinatal MDC 16 Blood & Blood Forming Organs MDC 17 Myeloproliferative MDC 18 Infectious & Parasitic Diseases MDC 19 Mental Diseases MDC 20 Alcohol & Drug Use MDC 21 Injuries, Poisonings MDC 22 Burns MDC 23 Factors Influencing Health Status MDC 24 Multiple Significant Trauma MDC 25 HIV 9

10 MDC DRG CC/MCC Relationship MDC SURGICAL Diagnosis Related Groups (Base DRGs) MEDICAL Diagnosis Related Groups (Base DRGs) With MCC With CC Without CC/MCC? 10

11 Case Example #1 Principal diagnosis acute respiratory failure (J96.00) Secondary diagnoses Pneumonia (J18.9 MCC) Ischemic CVA (I63.9 MCC) Developed after admission Principal procedure mechanical ventilation > 96 hrs. (5A1955Z) 11

12 MS DRG Assignment The Steps Step 1: Look up procedure in Index to Procedures Step 2: Determine MDC of principal diagnosis = MDC 4 (Respiratory System) Step 3: Determine if any procedure options are within that MDC Page 1 = Pre MDCs (mostly transplant DRGs) Page 109 = MDC 4 Respiratory System Page 618 = MDC 18 Infectious and Parasitic Diseases Page 762 & 768 = MDC 22 Burns <Source: 2018 DRG Expert by Optum> Identify page numbers, not DRGs 12

13 Respiratory System SURGICAL Major Chest Procedures Other Respiratory System O.R. Procedures Respiratory System MEDICAL Pulmonary Embolism Respiratory Infections and Inflammations Respiratory Neoplasms Major Chest Trauma Pleural Effusion Pulmonary Edema and Respiratory Failure COPD Simple Pneumonia & Pleurisy Interstitial Lung Disease Pneumothorax Bronchitis & Asthma Respiratory Signs & Symptoms Other Respiratory System Diagnoses Respiratory System Diagnosis with Ventilator Support > 96 Hours Respiratory System Diagnosis with Ventilator Support 96 Hours 13

14 Case Example #1 Answer Principal diagnosis acute respiratory failure (J96.00) Secondary diagnoses Pneumonia (J18.9 MCC) Ischemic CVA (I63.9 MCC) Developed after admission Principal procedure mechanical ventilation > 96 hrs. (5A1955Z) MDC 4 Respiratory System DRG 207 Respiratory System Diagnosis with Ventilator Support for > 96 Hours (RW $33,072) 14

15 Case Example #2 Principal diagnosis Ischemic CVA (I63.9) Secondary diagnoses Pneumonia (J18.9 MCC) Acute respiratory failure (J96.00 MCC) Developed after admission Principal procedure mechanical ventilation > 96 hrs. (5A1955Z) 15

16 MS DRG Assignment The Steps Step 1: Look up procedure in Index to Procedures Step 2: Determine MDC of principal diagnosis = MDC 1 (Nervous System) Step 3: Determine if any procedure options are within that MDC Page 1 = Pre MDCs (mostly Transplant DRGs) Page 109 = MDC 4 Respiratory System Page 618 = MDC 18 Infectious and Parasitic Diseases Page 762 & 768 = MDC 22 Burns <Source: 2018 DRG Expert by Optum> 16

17 Nervous System SURGICAL Intracranial Vascular Procedures with PDX of Hemorrhage Craniotomy w/major Device Implant/ Acute CNS PDX or Chemotherapy Implant or Epilepsy w/neurostimulator Craniotomy/Endovascular Intracranial Procedures Spinal Procedures or Spinal Neurostimulator Ventricular Shunt Procedures Carotid Artery Stent Procedures Extracranial Procedures Peripheral/Cranial Nerve/Other Nerve Procedures NONE of the surgical DRGs mention mechanical ventilation??? Nervous System MEDICAL Spinal Disorders/Injuries Nervous System Neoplasms Degenerative NS Disorders MS/Cerebellar Ataxia Acute Ischemic Stroke w/thrombolytic Intracranial Hemorrhage or Infarction Nonspec CVA and Precerebral Occlusion w/o Infarct TIA CAUTION!! Sometimes ICD 10 PCS procedures may impact some DRGs but not all Nonspecific Cerebrovascular Disorders Cranial and Peripheral Nerve Disorders Viral Meningitis Hypertensive Encephalopathy Nontraumatic Stupor/Coma Traumatic Stupor/Coma, > than one hour Concussion Other Disorders of Nervous System 17

18 Case Example #2 Answer Principal diagnosis Ischemic CVA (I63.9) Secondary diagnoses Pneumonia (J18.9 MCC) Acute respiratory failure (J96.00 MCC) Developed after admission Principal procedure mechanical ventilation > 96 hrs. (5A1955Z) MDC 1 Nervous System Difference $22,408!! DRG 064 Intracranial Hemorrhage or Cerebral Infarction with MCC (RW $10,664) 18

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20 Polling Question #1 A principal diagnosis of a traumatic injury to the hip can be assigned a DRG in which MDC? MDC 8 Musculoskeletal System MDC 21 Injuries MDC 1 Pre MDCs (Transplant and ECMO DRGs) MDCs Associated with All DRGs (O.R. Procedures Unrelated to the Principal Diagnoses) All of the above 20

21 Case Example #3 Principal diagnosis traumatic fracture, intertrochanteric, right femur, initial (S72.141A) Principal procedure replacement, right hip joint, open, synthetic substitute (0SR90JZ) 21

22 MS DRG Assignment The Steps Step 1: Look up procedure in Index to Procedures Step 2: Determine MDC of principal diagnosis = MDC 8 (Musculoskeletal System) Step 3: Determine if any procedure options are within that MDC Page 216, 218, 219 = MDC 8 Musculoskeletal System Page 713 = MDC 21 Injuries, Poisonings Page 500 = MDC 10 Endocrine, Nutritional and Metabolic Diseases Page 830 = MDC 24 Multiple Significant Trauma <Source: 2018 DRG Expert by Optum> 22

23 Musculoskeletal System MEDICAL Fractures of Femur Fractures of Hip/Pelvis Musculoskeletal System MEDICAL Medical Back Problems Bone Diseases and Arthropathies Sprains, Strains, Dislocations of Hip, Pelvis/Thigh Osteomyelitis Signs/Symptoms or MS and Connective Tissue Tendonitis, Myositis/Bursitis Pathological Fractures, MS and Connective Tissue Malignancy Connective Tissue Disorders Septic Arthritis Aftercare, MS and Connective Tissues Fracture, Sprain, Strain, Dislocation Except Femur, Hip, Pelvis and Thigh Other MS and Connective Tissue Diagnoses 23

24 Musculoskeletal System SURGICAL Combined Anterior/Posterior Spinal Fusion Spinal Fusion Exception Cervical with Spinal Curvature/Malignancy/Infection or Extensive Fusions Spinal Fusions Except Cervical Bilateral or Multiple Major Joint Procedures of Lower Extremity Wound Debridement & Skin Graft Except Hand, for MS Connective Tissue Disorder Revision of Hip/Knee Replacement Major Hip/Knee Replacement or Reattach of LE or TAR Cervical Spinal Fusion Amputation for MS & Connective Tissue Disorders Biopsies of MS & Connective Tissue Hip/Femur Procedures Except Major Joint Musculoskeletal System SURGICAL Knee Procedures without PDX of Infection Back/Neck Procedures Except Spinal Fusions Lower Extremity/Humerus Procs Except Hip, Foot, Femur Local Excision and Removal Internal Fixation Devices Except Hip/Femur Local Excision and Removal Internal Fixation Devices of Hip/Femur Soft Tissue Procedures Foot Procedures Major Thumb or Joint Procedures Major Shoulder or Elbow Joint Procedures Arthroscopy Shoulder, Elbow or Forearm Procedures, Except Major Joint Procs Major Joint/Limb Reattachment Proc of Upper Extremities Knee Procedures with PDX of Infection Hand or Wrist Procs, Except Major Thumb or Joint Procedures Other Musculoskeletal System and Connective Tissue O.R. Procedures 24

25 Case Example #3 Answer Principal diagnosis traumatic fracture, intertrochanteric, right femur, initial (S72.141A) Principal procedure replacement, right hip joint, open, synthetic substitute (0SR90JZ) MDC 8 Musculoskeletal System DRG 470 Major Joint Replacement or Reattachment of Lower Extremity without MCC (RW $12,384) 25

26 Case Example #4 Principal diagnosis crushing injury of right hip, initial (S77.01XA) Principal procedure replacement, right hip joint, open, synthetic substitute (0SR90JZ) 26

27 MS DRG Assignment The Steps Step 1: Look up procedure in Index to Procedures Step 2: Determine MDC of principal diagnosis = MDC 21 (Injuries, Poisonings) Step 3: Determine if any procedure options are within that MDC Page 216, 218, 219 = MDC 8 Musculoskeletal System Page 713 = MDC 21 Injuries, Poisonings Page 500 = MDC 10 Endocrine, Nutritional and Metabolic Diseases Page 830 = MDC 24 Multiple Significant Trauma <Source: 2018 DRG Expert by Optum> 27

28 Injuries, Poisoning SURGICAL Injuries, Poisoning MEDICAL Wound Debridements for Injuries Traumatic Injury Skin Grafts for Injuries Allergic Reactions Hand Procedures for Injuries Poisoning and Toxic Effects of Drugs Other O.R. Procedures for Injuries Complications of Treatment Other Injury, Poisoning and Toxic Effect Diagnoses 28

29 Case Example #4 Answer Principal diagnosis crushing injury of right hip, initial (S77.01XA) Principal procedure replacement, right hip joint, open, synthetic substitute (0SR90JZ) MDC 21 Injuries, Poisonings and Toxic Effects of Drugs DRG 909 Other O.R. Procedures for Injuries without CC/MCC (RW $8479) Difference $3905!! 29

30 Special MS DRGs Pre MDC and DRGs Associated With ALL MDCs Pre MDC DRGs associated with All MDCs Transplants and ECMO Principal diagnoses that do not match the principal procedure 30

31 Pre MDCs Seventeen MS DRGs assigned SOLELY off the procedure code reported Includes procedures like: Heart transplant or implant of heart assist system ECMO/tracheostomy Liver transplant Lung transplant Bone marrow transplant Pancreas transplant Intestinal transplant 31

32 Case Example #5 Q&A Principal diagnosis contusion of right hip, initial encounter (S70.01XA) Principal procedure transplant, right lung, open, allogeneic (0BYK0Z0) Pre MDC DRG 007 Lung Transplant (RW $58,997) 32

33 Case Example #6 Principal diagnosis traumatic fracture, intertrochanteric, right femur, initial (S72.141A) Secondary diagnosis acute STEMI, LAD (I21.02 MCC) Occurred 1 day after admission prior to scheduled ORIF Principal procedure bypass, coronary artery, one artery, open, no device, left internal mammary artery (02100Z9) Secondary procedure reposition, right upper femur, closed (0QS6XZZ) A closed reduction is an EXTERNAL approach and is considered non surgical 33

34 MS DRG Assignment The Steps Step 1: Look up procedure in Index to Procedures Only MDC for a CABG Can we assign the is 5 (Circulatory)? AMI as the principal Principal diagnosis is Step 2: Determine MDC of principal diagnosis = MDC 8 diagnosis (Musculoskeletal so they System) in MDC 8 MATCH? Musculoskeletal? Grouping Step 3: Determine to DRGs if any procedure options are within that MDC ?? Page 117 = MDC 5 DRGs Coronary Bypass w/ptca w/w/o MCC DRGs Coronary Bypass w/cardiac Cath w/w/o MCC DRGs Coronary Bypass w/o Cardiac Cath w/w/o MCC <Source: 2018 DRG Expert by Optum> 34

35 Case Example #5 Answer Principal diagnosis traumatic fracture, intertrochanteric, right femur, initial (S72.141A) Secondary diagnosis acute STEMI, LAD (I21.02 MCC) Occurred 1 day after admission prior to scheduled ORIF Principal procedure bypass, coronary artery, one artery, open, no device, left internal mammary artery (02100Z9) Secondary procedure reposition, right upper femur, closed (0QS6XZZ) DRG associated with ALL MDCs DRG 981 Extensive O.R. Procedure Unrelated to the Principal Diagnosis with MCC (RW $25,985) 35

36 Two Sides to Every Story For each MS DRG: Operating Portion Capital Portion Is there more logic behind each door? 36

37 Other Factors That Impact Financial Outcome Operating Portion Hospital s wage index ( 1.00 >) Relative weight of the DRG (±) Disproportionate Share Hospital (DSH) (+) Indirect medical education (IME) (+) Electronic health record (EHR) meaning user standards ( ) Inpatient Quality Reporting Program ( ) Hospital Readmissions Reduction Program (HRRP) ( ) Value Based Purchasing (VBP) (±) New Technology add on (+) Cost based outlier payment (+) SCH or Low Volume designation (+) Capital Portion Geographic adjustment factor (GAF) (±) Relative weight of the DRG (±) DSH adjustment (+) IME adjustment (+) Cost based outlier payment (+) 37

38 CMS Inpatient Pricer for MS DRG 064 DSH: disproportionate share of low income patients, which includes Medicaid/non Medicare patients and disabled Medicare patients IME: compensates teaching hospitals for the higher costs they incur relative to non teaching hospitals 38

39 CMS Inpatient Pricer for MS DRG 207 HRRP: reduction to account for excess readmissions for selected conditions VBP: may be a positive or negative adjustment from a 2% funding pool withheld from all hospital payments 39

40 Other Factors That Impact Financial Outcome Hospital s total payment may be adjusted Hospital Acquired Condition Reduction Program (HACRP) POA = No or Undetermined may affect DRG payment HAC diagnosis list on CMS website» Fee for Service Payment/HospitalAcqCond/icd10_hacs.html 1% reduction in payment for hospitals in lowest quartile for specific domains Reduction applies to all DRGs for entire FY Verify that assignment of POA is based on when IP order was written and not based on being clinically related to the admission POA = Y or W are conditions that were present prior to order POA = N or U are conditions that were not present prior to order 40

41 CMS Inpatient Pricer for MS DRG 983 HAC Impact J18.9 Pneumonia (Principal diagnosis) S72.141A Traumatic hip fracture (MCC but POA=N) W06.xxxA Fall from bed 0QS606Z ORIF (Principal procedure) POA = N cancels MCC and prevents higher DRG payment HACRP: overall, this facility does not fall into the lowest quartile for the 1% reduction for all DRG payments in that FY $11, vs. $11, < $115.07> 41

42 Other Factors That Impact Financial Outcome Hospital s total payment may be adjusted Discharge paid as a transfer Patient is admitted to another hospital on the day of discharge Includes regular transfer (02) and AMA (07) Patient is discharged with a qualifying MS DRG to a post acute care setting 280 post acute care transfer MS DRGs listed in Table 5 of IPPS final rule» Fee for Service Payment/AcuteInpatientPPS/FY2018 IPPS Final Rule Home Page Items/FY2018 IPPS Final Rule Tables.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=as cending» MLN Matters SE1411 lists discharge status codes SNF (03) or home health (06) 42

43 Other Factors That Impact Financial Outcome PACT formula using MS DRG 207 TABLE 5. LIST OF MEDICARE SEVERITY DIAGNOSIS RELATED GROUPS (MS DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY FY 2018 Correction Notice MS DRG MDC TYPE MS DRG Title Weights Geometric mean LOS FY 2018 Final Post Acute DRG FY 2018 Final Special Pay DRG 207 Yes No 04 MED RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS Take the hospital specific total payment and divide by the MS DRG s GMLOS Per diem amount for this hospital/this DRG Payment is based on actual LOS and discharge to post acute setting such as SNF or home health 2. Hospital is paid per diem X2 on first day 3. Subsequent days paid at 1 per diem up to full MS DRG See the following slide for an example 43

44 CMS Inpatient Pricer for MS DRG 207 MS DRG 207 (PACT) with D/C to SNF = Day 1 payment = $6, Days 2 6 payment = $15, (each day = $3,004.23) Total MS DRG payment for LOS 6 days & discharge to SNF = $21,

45 There s One More Thing Interaction between the revenue cycle and revenue integrity It s a team effort! Registration Pre authorization Scheduling C Suite Medical Staff Leadership Credentialing & Licensure Contracting Compliance & Audit CDI Physicians Clinicians (CM/UR/QI/departments) Coders Denials Prevention Edit Management Financial Counseling CDM & Charge Capture/Review HIM PFS IT 45

46 MS DRGs Demystified Many moving parts to MS DRG assignment Understanding the grouper is just the beginning Know where the MDC fork in the road will lead you What you see is not always what you get Other adjustments ultimately impact the final payment Understand the past so you can identify opportunities for improvement Transparent revenue cycle leads to revenue integrity Know what you know and (more importantly) what you don t There is no I in team collaborate and communicate 46

47 Thank you. Questions? In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide. 47