DRG Expert A comprehensive guidebook to the MS-DRG classification system Changes effective with discharges on or after October 1, 2015 2016 32nd Edition
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... 102 MDC 10 Endocrine, Nutritional And Metabolic Diseases And Disorders... 110 MDC 11 Diseases And Disorders Of The Kidney And Urinary Tract... 115 MDC 12 Diseases And Disorders Of The Male Reproductive System... 121 MDC 13 Diseases And Disorders Of The Female Reproductive System... 125 MDC 14 Pregnancy, Childbirth And The Puerperium... 132 MDC 15 Newborns And Other Neonates With Conditions Originating In The Perinatal Period... 162 MDC 16 Diseases And Disorders Of The Blood And Blood-Forming Organs And Immunological Disorders...174 MDC 17 Myeloproliferative Diseases And Disorders And Poorly Differentiated Neoplasms...177 MDC 18 Infectious And Parasitic Diseases, Systemic or Unspecified Sites...183 MDC 19 Mental Diseases And Disorders...187 MDC 20 Alcohol/Drug Use And Alcohol/Drug- Induced Organic Mental Disorders...190 MDC 21 Injuries, Poisonings And Toxic Effects Of Drugs...192 MDC 22 Burns...205 MDC 23 Factors Influencing Health Status And Other Contacts With Health Services...211 MDC 24 Multiple Significant Trauma...216 MDC 25 Human Immunodeficiency Virus Infections...229 DRGs Associated with All MDCs...232 Alphabetic Index to Diseases...237 Numeric Index to Diseases...313 Alphabetic Index to Procedures...389 Numeric Index to Procedures...411 Appendix A Lists of CCs and MCCs...433 Appendix B MS-DRG Surgical Hierarchy Table...555 Appendix C MS-LTC-DRG Crosswalk...559 Appendix D National Average Payment Table...577 Appendix E 2013 MedPAR National Data...597 Appendix F Medicare Case Mix Index Data...619 Glossary of DRG Terms...621
Diseases And Disorders Of The Circulatory System MDC 5 DRG 223 DRG 226 785.51 Cardiogenic shock Operating Room Procedures 00.51 Implantation of cardiac resynchronization defibrillator, total system (CRT-D) 17.51 Implantation of rechargeable cardiac contractility modulation [CCM], total system 37.94 Implantation or replacement of automatic cardioverter/ defibrillator, total system (AICD) Any of the following procedure combinations 00.52 Implantation or replacement of transvenous lead (electrode) into left ventricular coronary venous system 37.98 Replacement of automatic cardioverter/defibrillator pulse 37.95 Implantation of automatic cardioverter/defibrillator leads(s) 37.95 Implantation of automatic cardioverter/defibrillator leads(s) 37.97 Replacement of automatic cardioverter/defibrillator leads(s) 37.97 Replacement of automatic cardioverter/defibrillator leads(s) 37.98 Replacement of automatic cardioverter/defibrillator pulse Nonoperating Room Procedures 37.21 Right heart cardiac catheterization 37.22 Left heart cardiac catheterization 37.23 Combined right and left heart cardiac catheterization 88.52 Angiocardiography of right heart structures 88.53 Angiocardiography of left heart structures 88.54 Combined right and left heart angiocardiography 88.55 Coronary arteriography using single catheter 88.56 Coronary arteriography using two catheters 88.57 Other and unspecified coronary arteriography 88.58 Negative-contrast cardiac roentgenography DRG 223 with Acute Myocardial Infarction/Heart Failure/Shock without MCC GMLOS 4.4 AMLOS 6.0 RW 6.2924 4 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 7.6733 4 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 5.8610 4 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 6.9573 4 Operating Room Procedures 00.51 Implantation of cardiac resynchronization defibrillator, total system (CRT-D) 17.51 Implantation of rechargeable cardiac contractility modulation [CCM], total system 37.94 Implantation or replacement of automatic cardioverter/ defibrillator, total system (AICD) Any of the following procedure combinations 00.52 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 10/01/2015-09/30/2016 57
Alphabetic Index to Diseases 765.22 24 completed weeks of gestation 163 765.23 25-26 completed weeks of gestation 163 765.24 27-28 completed weeks of gestation 163, 167 765.25 29-30 completed weeks of gestation 163, 167 765.26 31-32 completed weeks of gestation 163, 167 765.27 33-34 completed weeks of gestation 163, 167 765.28 35-36 completed weeks of gestation 163, 167 765.29 37 or more completed weeks of gestation 171, 172 039.2 Abdominal actinomycotic infection 75 441.4 Abdominal aneurysm without mention of rupture 66 441.3 Abdominal aneurysm, ruptured 66 902.0 Abdominal aorta injury 166, 170 789.3* Abdominal or pelvic swelling, mass, or lump 78 789.0* Abdominal pain 78 789.4* Abdominal rigidity 79 789.6* Abdominal tenderness 78 786.7 Abnormal chest sounds 54 796.7* Abnormal cytologic smear of anus and anal HPV 79 796.5 Abnormal finding on antenatal screening 156, 159 790.2* Abnormal glucose 113 374.43 Abnormal innervation syndrome of eyelid 39 781.0 Abnormal involuntary movements 33 783.2* Abnormal loss of weight 231 648.84 Abnormal maternal glucose tolerance complicating pregnancy, childbirth, or the puerperium, postpartum condition or complication 152 648.83 Abnormal maternal glucose tolerance, antepartum 154, 156 648.80 Abnormal maternal glucose tolerance, complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care 159 648.81 Abnormal maternal glucose tolerance, with delivery 134, 142, 148 648.82 Abnormal maternal glucose tolerance, with delivery, with current postpartum complication 135, 142, 148 795.0* Abnormal Papanicolaou smear of cervix and cervical HPV 127, 130 795.1* Abnormal Papanicolaou smear of vagina and vaginal HPV 127, 130 781.92 Abnormal posture 33 796.1 Abnormal reflex 33 786.4 Abnormal sputum 54 795.8* Abnormal tumor markers 213 659.73 Abnormality in fetal heart rate or rhythm, antepartum condition or complication 155, 158 659.71 Abnormality in fetal heart rate or rhythm, delivered, with or without mention of antepartum condition 136, 143, 149 659.70 Abnormality in fetal heart rate or rhythm, unspecified as to episode of care or not applicable 136, 143, 149 781.2 Abnormality of gait 33 790.0* Abnormality of red blood cells 175 251.5 Abnormality of secretion of gastrin 77 251.4 Abnormality of secretion of glucagon 114 999.6* ABO incompatibility reaction due to transfusion of blood or blood products 167, 171, 176 637* Abortion, unspecified as to legality 153 915.0 Abrasion or friction burn of finger, without mention of infection 107 917.0 Abrasion or friction burn of foot and toe(s), without mention of infection 107 919.0 Abrasion or friction burn of other, multiple, and unspecified sites, without mention of infection 107 566 Abscess of anal and rectal regions 79, 166, 170 616.3 Abscess of Bartholin s gland 127, 130 675.12 Abscess of breast associated with childbirth, delivered, with mention of postpartum complication 139, 141, 147 675.11 Abscess of breast associated with childbirth, delivered, with or without mention of antepartum condition 139, 141, 147 675.10 Abscess of breast associated with childbirth, unspecified as to episode of care 161 675.13 Abscess of breast, antepartum 156, 158 675.14 Abscess of breast, postpartum condition or complication 153 569.5 Abscess of intestine 76 572.0 Abscess of liver 166, 170 513* Abscess of lung and mediastinum 51, 165, 170 254.1 Abscess of thymus 164, 168 133* Acariasis 108 998.2 Accidental puncture or laceration during procedure 167, 171, 204 791.6 Acetonuria 113 530.0 Achalasia and cardiospasm 78 726.71 Achilles bursitis or tendinitis 99 536.0 Achlorhydria 78 368.54 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 215 388.45 Acquired auditory processing disorder 189 429.71 Acquired cardiac septal defect 69 286.7 Acquired coagulation factor deficiency 176 368.55 Acquired color vision deficiencies 38 593.2 Acquired cyst of kidney 120 736.3* Acquired deformities of hip 100 736.8* Acquired deformities of other parts of limbs 100 735* Acquired deformities of toe 100 738.3 Acquired deformity of chest and rib 100 736.9 Acquired deformity of limb, site unspecified 100 738.2 Acquired deformity of neck 100 738.0 Acquired deformity of nose 47 738.6 Acquired deformity of pelvis 100 736.71 Acquired equinovarus deformity 100 283.9 Acquired hemolytic anemia, unspecified 164, 169, 175 283* Acquired hemolytic anemias 230 286.52 Acquired hemophilia 176 537.0 Acquired hypertrophic pyloric stenosis 77 244* Acquired hypothyroidism 114 Alphabetic Index to Diseases 2015 Optum360, LLC *Code Range 237
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 28.6 36.8 25.3920 $137,098.26 002 HEART TRANSPLANT IMPLANT OF HEART ASSIST SYSTEM W/O MCC 15.7 18.7 15.6820 $84,671.35 T 003 ECMO TRACH W MV 96+ HRS PDX EXC FACE, MOUTH & NECK W MAJ O.R. 26.3 32.2 17.6399 $95,242.58 T 004 TRACH W MV 96+ HRS PDX EXC FACE, MOUTH & NECK W/O MAJ O.R. 20.2 24.4 10.8533 $58,599.90 005 LIVER TRANSPLANT W MCC INTESTINAL TRANSPLANT 15.2 20.7 10.4973 $56,677.76 006 LIVER TRANSPLANT W/O MCC 7.9 8.8 4.7461 $25,625.48 007 LUNG TRANSPLANT 15.9 18.6 9.2986 $50,205.65 008 SIMULTANEOUS PANCREAS/KIDNEY TRANSPLANT 9.8 11.3 5.3302 $28,779.19 010 PANCREAS TRANSPLANT 7.8 9.6 4.0849 $22,055.48 011 TRACHEOSTOMY F FACE,MOUTH & NECK DIAGNOSES W MCC 11.3 14.1 4.7380 $25,581.74 012 TRACHEOSTOMY F FACE,MOUTH & NECK DIAGNOSES W CC 8.4 10.0 3.3293 $17,975.79 013 TRACHEOSTOMY F FACE,MOUTH & NECK DIAGNOSES W/O CC/MCC 5.8 6.6 2.1357 $11,531.22 014 ALLOGENEIC BONE MARROW TRANSPLANT 20.0 25.1 10.9883 $59,328.80 016 AUTOLOGOUS BONE MARROW TRANSPLANT W CC/MCC 17.5 19.1 5.8780 $31,736.91 017 AUTOLOGOUS BONE MARROW TRANSPLANT W/O CC/MCC 8.9 12.4 4.1603 $22,462.58 020 INTRACRANIAL VASCULAR PROCEDURES W PDX HEMRHAGE W MCC 13.9 16.8 9.4423 $50,981.53 021 INTRACRANIAL VASCULAR PROCEDURES W PDX HEMRHAGE W CC 11.9 13.4 7.1555 $38,634.48 022 INTRACRANIAL VASCULAR PROCEDURES W PDX HEMRHAGE W/O CC/MCC 6.3 7.8 4.4934 $24,261.08 T 023 CRANIO W MAJ DEV IMPL/ACUTE COMPLEX CNS PDX W MCC CHEMO IMPLANT 7.9 11.0 5.2939 $28,583.20 T 024 CRANIO W MAJ DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC 4.4 6.3 3.7461 $20,226.21 T 025 CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC 7.4 9.7 4.3374 $23,418.79 T 026 CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC 4.7 6.1 3.0011 $16,203.75 T 027 CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC 2.5 3.3 2.2824 $12,323.29 t 028 SPINAL PROCEDURES W MCC 9.6 12.3 5.3968 $29,138.78 t 029 SPINAL PROCEDURES W CC SPINAL NEUROSTIMULATS 4.8 6.4 3.1573 $17,047.12 t 030 SPINAL PROCEDURES W/O CC/MCC 2.6 3.4 1.7835 $9,629.60 T 031 VENTRICULAR SHUNT PROCEDURES W MCC 7.7 11.0 4.1493 $22,403.19 T 032 VENTRICULAR SHUNT PROCEDURES W CC 3.3 4.7 2.0325 $10,974.02 T 033 VENTRICULAR SHUNT PROCEDURES W/O CC/MCC 2.0 2.5 1.5602 $8,423.94 034 CAROTID ARTERY STENT PROCEDURE W MCC 4.5 6.6 3.7008 $19,981.62 Calculated with an average hospital Medicare base rate of $5,399.27. 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