Impact of Guidelines on DRG s APRIL 25, 2017 38th EDUCATIONAL MEETING & INSTALLATION LUNCHEON
Abstract Official Coding Guidelines/Coding Clinic instructions have different impacts on the MS-DRG and APR-DRG grouper logic. Compliant application of coding guidelines and instructions will affect the CMI, and impact the DRG assignment. Today s presentation will overview a sample of key guidelines, coding clinic advice, and code book instructions to illustrate the MS-DRG/APR-DRG differences. RRA, Inc. 2
Learning Objectives Recall the guidelines for injury/trauma/complication for sequence and code instructions Examine code book instructions for code first, code additional to completely capture missed CC/MCC/SOI Identify Coding Clinic advice that generates significant procedures for DRG impact Compare the grouper impact for MS-DRGs and APR-DRGs on specific examples RRA, Inc. 3
Official Coding Guidelines CMS official coding guidelines are updated and published each fiscal year effective Oct 1 Sept 30 of each year Official coding guidelines for diagnoses are located in the front of the ICD-10-CM code book Official coding guidelines for procedures are located in the front of the ICD-10-PCS code book The complete official coding guideline versions for CM and PCS can also be found on the CMS website RRA, Inc. 4
Key Concept for Coding Accuracy Official Coding Guidelines for CM/PCS take priority over any Coding Clinic Advice RRA, Inc. 5
Injury Sequencing ICD-10-CM Official Coding Guidelines 2017 Chapter 19 C.19.b.(1).(2) b. Traumatic injury codes (S00-T14.9) are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds. The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first. 1) Superficial injuries Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site. 2) Primary injury with damage to nerves/blood vessels When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is sequenced first with additional code(s) for injuries to nerves and spinal cord (such as category S04), and/or injury to blood vessels (such as category S15). When the primary injury is to the blood vessels or nerves, that injury should be sequenced first. RRA, Inc. 6
Injury Sequencing Example: Open laceration of upper arm rt side with small blood vessel oozing, skin and sub-q tissue sutured MS- DRG S41.111A Laceration rt upper arm no foreign body S45.811A Laceration of other specified blood vessel at shoulder and upper arm level, rt arm 0JQD0ZZ- Repair, Sub Q tissue, rt upper arm, open, no device MS-DRG= 580 - Other skin, subcut tiss & breast proc w/o cc/mcc SIW = 1.6483 Reimb= $ 20,845.23 APR-DRG S41.111A Laceration rt upper arm no foreign body S45.811A Laceration of other specified blood vessel at shoulder and upper arm level, rt arm 0JQD0ZZ- Repair, Sub Q tissue, rt upper arm, open, no device APR-DRG= 364.1 -Other skin, subcutaneous tissue & related procedures SIW =.8556 Reimb= $ 8,884.02 RRA, Inc. 7
Injury Sequencing Example: laceration of upper arm rt side with arterial blood vessel injury, ligation (occlusion) of upper arm artery with skin/sub-q tissue sutured MS- DRG S45.811A Laceration of other specified blood vessel at shoulder and upper arm level, rt arm S41.111A Laceration rt upper arm no foreign body 03LY0ZZ- Occlusion, upper artery, open 0JQD0ZZ- Repair, Sub Q tissue, rt upper arm, open no device MS-DRG= 909 - Other O.R. Procedures for injuries w/o cc/mcc SIW = 1.3110 Reimb= $20,983.92 $100 APR-DRG S45.811A Laceration of other specified blood vessel at shoulder and upper arm level, rt arm S41.111A Laceration rt upper arm no foreign body 03LY0ZZ- Occlusion, upper artery, open 0JQD0ZZ- Repair, Sub Q tissue, rt upper arm, open no device APR-DRG= 173.1 - Other vascular procedures SIW = 1.5220 Reimb= $15,512.55* 7K RRA, Inc. 8
Injury Use Additional Code ICD-10-CM Official Coding Guidelines 2017 3) Non-healing burns Non-healing burns are coded as acute burns. 4) Infected Burn For any documented infected burn site, use an additional code for the infection. Chapter 19 C.19.d. (3).(4) complication of burns RRA, Inc. 9
Example: Burn Second and third degree burn bilateral lower legs, TBS = 3 rd degree 12 % of total burn surface. Day 3 hospital stay red swollen calf on the left, and knee swelling redness on the right side. Obvious infected burn draining greenish liquid, started on abx, Infectious disease consult ordered. Today fluctuating mass over the right knee, seen by Surgery. Surgeon performed I&D of right knee abscess, sub-q level of tissue open. Split thickness skin graft, synthetic, external. Cultures return + for MRSA. MS- DRG T24.302A 3 rd degree burn left lower limb T24.202A -2 nd degree burn left lower limb T24.201A 2 nd degree burn right lower limb T24.301A- 3 rd degree burn right lower limb T31.11 TBS 10-19% with 10-19% 3 rd degree burn L03.116 - Cellulitis left calf L02.415- Abscess rt knee A49.02 MRSA infection 0J9N0ZX- Drainage knee rt side, sub-q tissue, open, diagnostic 0HRLXJ4- Replace left lower leg skin, synth, partial thick,external MS-DRG= 928 - Full thickness burn w skin graft or inhal inj w cc/mcc SIW = 5.1947 Reimb= $65,443.42 APR-DRG T24.302A 3 rd degree burn left lower limb T24.202A -2 nd degree burn left lower limb T24.201A 2 nd degree burn right lower limb T24.301A- 3 rd degree burn right lower limb T31.11 TBS 10-19% with 10-19% 3 rd degree burn L03.116 - Cellulitis left calf L02.415- Abscess rt knee A49.02 MRSA infection 0J9N0ZX- Drainage knee rt side, sub-q tissue, open, diagnostic 0HRLXJ4- Replace left lower leg skin, synth, partial thick,external APR-DRG=842.3 - Full thickness burns w skin graft SIW = 4.6277 Reimb= $44,657.49 RRA, Inc. 10
Example: Burn Second and third degree burn bilateral lower legs, 4 days ago. Treated at Community hospital and discharged yesterday. TBS = 3 rd degree 12 % of total burn surface. Returns to the emergency room with red swollen calf on the left, and knee swelling redness on the right side. Obvious infected burn draining greenish liquid, started on abx, Infectious disease consult ordered. Today fluctuating mass over the right knee, seen by Surgery performed I&D of right knee abscess, sub-q level of tissue, open. Split thickness skin graft, synthetic, external. Cultures return + for MRSA. MS- DRG L03.116 - Cellulitis left calf L02.415- Abscess rt knee T24.202A -2 nd degree burn left lower limb T24.302A 3 rd degree burn left lower limb T24.201A 2 nd degree burn right lower limb T24.301A- 3 rd degree burn right lower limb T31.11 TBS 10-19% with 10-19% 3 rd degree burn A49.02 MRSA infection 0J9N0ZX- Drainage knee rt side, sub-q tissue, open, diagnostic 0HRLXJ4- Replace left lower leg skin, synth, partial thick,external MS-DRG= 574 - Skin graft for skin ulcer or cellulitis W cc SIW = 2.8569 Reimb= $38,668.95 27K APR-DRG L03.116 - Cellulitis left calf L02.415- Abscess rt knee T24.202A -2 nd degree burn left lower limb T24.302A 3 rd degree burn left lower limb T24.201A 2 nd degree burn right lower limb T24.301A- 3 rd degree burn right lower limb T31.11 TBS 10-19% with 10-19% 3 rd degree burn A49.02 MRSA infection 0J9N0ZX- Drainage knee rt side, sub-q tissue, open, diagnostic 0HRLXJ4- Replace left lower leg skin, synth, partial thick,external APR-DRG= 361.3 - Skin graft for skin & subcutaneous tissue diagnoses SIW = 3.6633 Reimb= $ 35,744.85 9K RRA, Inc. 11
Complications of care ICD-10-CM Official Coding Guidelines 2017 Chapter 19 5) Complications of care codes within the body system chapters Intraoperative and postprocedural complication codes are found within the body system chapters with codes specific to the organs and structures of that body system. These codes should be sequenced first, followed by a code(s) for the specific complication, if applicable. C.19.g.(5) Complications of care RRA, Inc. 12
MS- DRG APR-DRG Example: Complication of care Post operative pulmonary embolism Without the complication code added I26.99 - Pulmonary embolism MS-DRG= 176 - Pulmonary embolism w/o mcc SIW =.9129 Reimb= $16,426.58 I26.99 - Pulmonary embolism APR-DRG= 134.1 -Pulmonary embolism SIW =.7738 Reimb= $9,041.13 RRA, Inc. 13
Example: Complication of care Post operative pulmonary embolism With the complication code Added See excludes note and code also note for code I2609 Excludes Post operative Pulm Embolism Code T817-, See code T81718A -code also the condition/complication. Sequence I2609 as the secondary diagnosis. Code added as px dx T81718A, DRG changes. MS-DRG T81.718- Complication of other artery following a procedure, not elsewhere classified I26.99 - Pulmonary embolism, with no corpulmonale * cc is excluded MS-DRG= 301 - Peripheral vascular disorders w/o cc/mcc SIW =.9129 Reimb= $ 16,426.58 APR-DRG T81.718- Complication of other artery following a procedure, not elsewhere classified I26.99 - Pulmonary embolism, with no cor-pulmonale * not excluded from impacting as SOI (3) APR-DRG= 197.3 - Peripheral & other vascular disorders SIW = 1.2112 Reimb= $13,083.42 * 8K RRA, Inc. 14
Injury Sequencing Early Complication(s) of Trauma Fractured right mandible, treated with closed reduction 2 days earlier, Now admitted for Pain control of Severe Traumatic Pain MS- DRG G89.11- Acute pain due to trauma S02.601 - A Fracture rt mandible, initial care MS-DRG= 948 -Signs & symptoms w/o mcc SIW =.7463 Reimb= $14,519.39* resequenced lower reimb by 1K APR-DRG G89.11- Acute pain due to trauma S02.601 - A Fracture rt mandible, initial care APR-DRG= 861.2 Signs, symptoms & other factors influencing health status SIW =.5690 Reimb= $7,148.44* resequenced lower reimb by 1K RRA, Inc. 15
Sequencing and Procedures impacted by Guidelines Official Coding Guidelines PCS B.3 Root Operation Biopsy procedures B3.4a Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic. Examples: Fine needle aspiration biopsy of fluid in the lung is coded to the root operation Drainage with the qualifier Diagnostic. Biopsy of bone marrow is coded to the root operation Extraction with the qualifier Diagnostic. Lymph node sampling for biopsy is coded to the root operation Excision with the qualifier Diagnostic. RRA, Inc. 16
Injury Sequencing & Procedures Early Complication(s) of Trauma s/p laceration left hand treated in ER 2 days earlier, now with large volar abscess left hand due to early complication of trauma, admit for surgical drainage, sub-q, open, fluid sent for diagnosis ( diagnostic qualifier) NO O.R. impact MS- DRG T79.8XXA Other early complications of trauma, initial L02.512- Cutaneous abscess left hand S61.412A- Laceration without Foreign body left hand 0J9K0ZX- Drainage sub-q, left hand, open, diagnostic MS-DRG= 923 - Other injury, poisoning & toxic effect diag w/o mcc SIW =.8218 Reimb= $15,383.70 APR-DRG T79.8XXA Other early complications of trauma, initial L02.512- Cutaneous abscess left hand S61.412A- Laceration without Foreign body left hand 0J9K0ZX- Drainage sub-q, left hand, open, diagnostic APR-DRG= 815.1 Other injury, poisoning & toxic effect diagnoses- SIW =.3116 Reimb= $ 4,769.65 RRA, Inc. 17
Injury Sequencing & Procedures Early Complication(s) of Trauma s/p laceration left hand treated in ER 2 days earlier, now with large volar abscess left hand due to early complication of trauma, admit for surgical drainage, sub-q, open, non diagnostic no fluid sent for testing ( no qualifier) O.R. Impact on DRG MS- DRG T79.8XXA Other early complications of trauma, initial L02.512- Cutaneous abscess left hand S61.412A- Laceration without Foreign body left hand 0J9K0ZZ- Drainage sub-q, left hand, open, no qualifier MS-DRG= 906 - Hand procedures for injuries SIW = 1.5037 Reimb= $ 23,189.89 8K APR-DRG T79.8XXA Other early complications of trauma, initial L02.512- Cutaneous abscess left hand S61.412A- Laceration without Foreign body left hand 0J9K0ZZ- Drainage sub-q, left hand, open, no qualifier APR-DRG= 952.1 - Nonextensive procedure unrelated to principal diagnosis SIW =.7435 Reimb= $ 8,761.11 4K RRA, Inc. 18
Injury Sequencing & Procedures s/p laceration left hand treated in ER 2 days earlier, now with large volar abscess left hand due to trauma, admit for surgical drainage, sub-q, open, non diagnostic no fluid sent for testing ( no qualifier) O.R. impact on Abscess code MS- DRG L02.512- Cutaneous abscess left hand S61.412A- Laceration without Foreign body left hand 0J9K0ZZ- Drainage sub-q, left hand, open, no qualifier MS-DRG= 581 -Other skin, subcutaneous tissue & breast proc w/o cc/mcc SIW = 1.2666 Reimb= $ 20,475.64 APR-DRG L02.512- Cutaneous abscess left hand S61.412A- Laceration without Foreign body left hand 0J9K0ZZ- Drainage sub-q, left hand, open, no qualifier APR-DRG= 364.1 - Other skin, subcutaneous tissue & related procedures SIW =.7568 Reimb= $ 8,884.02 RRA, Inc. 19
Expect the Official Coding Guideline instructions to change over time RRA, Inc. 20
Official Coding Guidelines Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) C.18.e.Coma Scale e. Coma scale The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition. The coma scale codes should be sequenced after the diagnosis code(s). These codes, one from each subcategory, are needed to complete the scale. The 7th character indicates when the scale was recorded. The 7th character should match for all three codes. At a minimum, report the initial score documented on presentation at your facility. This may be a score from the emergency medicine technician (EMT) or in the emergency department. If desired, a facility may choose to capture multiple coma scale scores. RRA, Inc. 21
Code Description CC/MCC R402110 Coma scale, eyes open, never, unspecified time MCC R402111 Coma scale, eyes open, never, in the field [EMT or ambulance] MCC R402112 Coma scale, eyes open, never, at arrival to emergency department MCC Individual Score GCS Codes R402113 R402114 R402210 Coma scale, eyes open, never, at hospital admission Coma scale, eyes open, never, 24 hours or more after hospital admission Coma scale, best verbal response, none, unspecified time MCC MCC MCC R402211 Coma scale, best verbal response, none, in the field [EMT or ambulance] MCC R402212 Coma scale, best verbal response, none, at arrival to emergency department MCC R402213 Coma scale, best verbal response, none, at hospital admission MCC R402214 Coma scale, best verbal response, none, 24 hours or more after hospital admission MCC R402310 Coma scale, best motor response, none, unspecified time MCC R402311 R402312 Coma scale, best motor response, none, in the field [EMT or ambulance] Coma scale, best motor response, none, at arrival to emergency department R402313 RRA, Inc. Coma scale, best motor response, none, at hospital admission MCC 22 MCC MCC
Code Description CC/MCC R402410 Glasgow coma scale score 13-15, unspecified time NONE R402411 Glasgow coma scale score 13-15, in the field [EMT or ambulance] NONE R402412 Glasgow coma scale score 13-15, at arrival to emergency department NONE Total GCS Codes R402413 R402414 R402420 Glasgow coma scale score 13-15, at hospital admission Glasgow coma scale score 13-15, 24 hours or more after hospital admission Glasgow coma scale score 9-12, unspecified time NONE NONE NONE IMPORTANT NOTE- NONE of the TOTAL GCS scores impact as CC/MCC/SOI - no matter how low the score! R402421 R402422 R402423 Glasgow coma scale score 9-12, in the field [EMT or ambulance] Glasgow coma scale score 9-12, at arrival to emergency department Glasgow coma scale score 9-12, at hospital admission NONE NONE NONE R402424 Glasgow coma scale score 9-12, 24 hours or more after hospital admission NONE R402430 Glasgow coma scale score 3-8, unspecified time NONE R402431 Glasgow coma scale score 3-8, in the field [EMT or ambulance] NONE R402432 Glasgow coma scale score 3-8, at arrival to emergency department NONE R402433 Glasgow coma scale score 3-8, at hospital admission NONE RRA, Inc. NONE 23 R402434 Glasgow coma scale score 3-8, 24 hours or more after hospital admission
Example: GCS with total score only 39 yr old male with traumatic subdural, GCS individual scores in the Emergency room Eyes (1), Verbal (1), Motor (1) hemorrhage, GCS total score of (3), on admit MS- DRG S065X4A- Traumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours, initial encounter R402433- Glasgow coma scale score 3-8, at hospital admission MS-DRG= 084 -Traumatic stupor & coma, coma >1 hr w/o cc/mcc SIW =.9262 Reimb= $ 16,578.44 R402112- Coma scale, eyes open, never, at arrival to emergency department R402212- Coma scale, best verbal response, none, at arrival to emergency department R402312- Coma scale, best motor response, none, at arrival to emergency department NO Change to DRG either way APR-DRG S065X4ATraumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours, initial encounter R402433- Glasgow coma scale score 3-8, at hospital admission APR-DRG= 055.1 - Head trauma w coma >1 hr or hemorrhage SIW =.5341 Reimb= $6,825.91 R402112- Coma scale, eyes open, never, at arrival to emergency department R402212- Coma scale, best verbal response, none, at arrival to emergency department R402312- Coma scale, best motor response, none, at arrival to emergency department NO Change to DRG either way RRA, Inc. 24
Example: GCS with individual scores 39 yr old male with diffuse traumatic brain injury with LOC > 24 hrs, no return with survival, GCS individual scores in the Emergency room Eyes (1), Verbal (1), Motor (1) MS- DRG S06.2X6A- Diffuse TBI with LOC > 24 hours with no return, with survival initial R402112- Coma scale, eyes open, never, at arrival to emergency department R402212- Coma scale, best verbal response, none, at arrival to emergency department R402312- Coma scale, best motor response, none, at arrival to emergency department MS-DRG= 084 - Traumatic stupor & coma, coma >1 hr w/o cc/mcc SIW =.9262 Reimb= $16,578.84 No impact APR-DRG S06.2X6A- Diffuse TBI with LOC > 24 hours with no return, with survival initial R402112- Coma scale, eyes open, never, at arrival to emergency department R402212- Coma scale, best verbal response, none, at arrival to emergency department R402312- Coma scale, best motor response, none, at arrival to emergency department APR-DRG= 065.2 - Head trauma w coma >1 hr or hemorrhage SIW =.8553 Reimb= $ 9,794.32 SOI (2) impact RRA, Inc. 25
Example: GCS with individual scores 39 yr old male with cerebral infarct due to thrombosis rt middle cerebral artery, GCS individual scores in the Emergency room Eyes (1), Verbal (1), Motor (1) MS- DRG I63.311- Cerebral infarct due to thrombosis right middle cerebral artery R402112- Coma scale, eyes open, never, at arrival to emergency department R402212- Coma scale, best verbal response, none, at arrival to emergency department R402312- Coma scale, best motor response, none, at arrival to emergency department MS-DRG= 064- Intracranial hemorrhage or cerebral infarction w mcc SIW =1.7518 Reimb= $23,030.07 W/MCC impact APR-DRG I63.311- Cerebral infarct due to thrombosis right middle cerebral artery R402112- Coma scale, eyes open, never, at arrival to emergency department R402212- Coma scale, best verbal response, none, at arrival to emergency department R402312- Coma scale, best motor response, none, at arrival to emergency department APR-DRG= 045.3 - CVA & precerebral occlusion w infarct SIW =. 1.6582 Reimb= $ 17,214.44 SOI (3) impact RRA, Inc. 26
Example: GCS with individual scores 39 yr old male with E. Coli Sepsis* with change of mental status, GCS individual scores on admit to ICU unit Eyes (1), Verbal (1), Motor (1) MS- DRG A4151 - Sepsis due to Escherichia coli [E. coli] R402113 - Coma scale, eyes open, never, at hospital admission R402213 - Coma scale, best verbal response, none, at hospital admission R402313 - Coma scale, best motor response, none, at hospital admission MS-DRG= 871 - Septicemia or severe sepsis w/o mv >96 hours w mcc SIW = 1.7660 Reimb= $ 26192.63 W/MCC impact APR-DRG A4151 -Sepsis due to Escherichia coli [E. coli] R402113 - Coma scale, eyes open, never, at hospital admission R402213 - Coma scale, best verbal response, none, at hospital admission R402313- Coma scale, best motor response, none, at hospital admission APR-DRG= 720.3 - Septicemia & disseminated infections SIW = 1.4945 Reimb= $15,701.58 SOI (3) Impact RRA, Inc. 27
What other principal diagnosis can you think of that might be impacted by individual GCS scores? P- From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) Sepsis- 3 RRA, Inc. 28
Key Concept for Coding Accuracy AHA Coding Clinic Advice is published quarterly. Each publication includes an effective with discharges date RRA, Inc. 29
Coding Clinic Advice Procedures on Tubular structures BAL- Correction notice See also Official Coding Guidelines PCS Coding Clinic Advice Coding Clinic First Quarter 2017 Correction Notices : Bronchoalveolar Lavage Coding Clinic, First Quarter 2016, page 26, contained an error regarding the appropriate ICD-10-PCS code for bronchoalveolar lavage (BAL). Code 0B9B8ZX, Drainage of left lower lobe bronchus via natural or artificial opening endoscopic, is not the correct code. BAL involves washing out and sampling alveoli of the lung (small sacs within the lungs). The appropriate code assignment for a BAL is as follows: 0B9J8ZX - Drainage of left lower lung lobe, via natural or artificial opening endoscopic, diagnostic The lung body part values more accurately capture the objective of bronchoalveolar lavage, and coding to the lung is consistent with the general PCS convention of coding treatment of a tubular body part to the furthest anatomical site reached. In this case it is alveolar (lung) tissue. Coding advice or code assignments contained in this issue effective with discharges March 13, 2017. Page 51---- What about corrections? Coding Clinic Advice Coding Clinic First Quarter 2016 Question: A fiberoptic bronchoscopy was performed due to abnormal radiologic findings of lung field. Brushings were obtained from the left upper lobe bronchus. Bronchial washings, bronchoalveolar lavage and the brushing specimens were submitted for studies. What are the ICD-10-PCS code assignments for the procedure? Answer: Assign the following ICD-10-PCS codes: 0B988ZX- Drainage of left upper lobe bronchus, via natural or artificial opening endoscopic, diagnostic, for the left bronchoalveolar lavage 0BB88ZX- Excision of left upper lobe bronchus, via natural or artificial opening endoscopic, diagnostic, for the bronchial washings and brushings of the left upper lobe bronchus RRA, Inc. 30
PCS Official Coding Guidelines Procedures on Tubular structures Official Coding Guidelines PCS B3. Root Operation Inspection B3.11b If multiple tubular body parts are inspected, the most distal body part (the body part furthest from the starting point of the inspection) is coded. If multiple non-tubular body parts in a region are inspected, the body part that specifies the entire area inspected is coded. Examples: Cystoureteroscopy with inspection of bladder and ureters is coded to the ureter body part value. Exploratory laparotomy with general inspection of abdominal contents is coded to the peritoneal cavity body part value. RRA, Inc. 31
Change with Reimbursement Consequences RRA, Inc. 32
Coding Clinic Advice DRG Impact Example: MRSA Sepsis, with MRSA Pneumonia with Rt lower lung lobe BAL (bronchus) Coding Clinic, Coding Clinic, First Quarter 2016 original advice No O.R. impact MS- DRG A4102-Sepsis due to Methicillin resistant Staphylococcus aureus J15212-Pneumonia due to Methicillin resistant Staphylococcus aureus 0B9B8ZX- Drainage of left lower lobe bronchus via natural or artificial opening endoscopic MS-DRG= 871 Septicemia or severe sepsis w/o mv >96 hours w mcc - SIW = 1.7660 Reimb= $26,192.63 APR-DRG A4102-Sepsis due to Methicillin resistant Staphylococcus aureus J15212-Pneumonia due to Methicillin resistant Staphylococcus aureus 0B9B8ZX - Drainage of left lower lobe bronchus via natural or artificial opening endoscopic APR-DRG= 720.2 - Septicemia & disseminated infections SIW =.8646 Reimb= $9,880.27 RRA, Inc. 33
Coding Clinic Advice DRG Impact Example: MRSA Sepsis, with MRSA Pneumonia with Rt lower lung lobe BAL (lung) Coding Clinic, First Quarter 2017, page 51, Correction notice O.R. impact on DRG MS- DRG A4102 - Sepsis due to Methicillin resistant Staphylococcus aureus J15212 - Pneumonia due to Methicillin resistant Staphylococcus aureus 0B9J8ZX - Drainage of left lower lung lobe, via natural or artificial opening endoscopic, diagnostic MS-DRG= 853 - Infectious & parasitic diseases w O.R. Procedure w mcc SIW = 5.1097 Reimb= $ 64,470.37 38K APR-DRG A4102 - Sepsis due to Methicillin resistant Staphylococcus aureus J15212 - Pneumonia due to Methicillin resistant Staphylococcus aureus 0B9J8ZX - Drainage of left lower lung lobe, via natural or artificial opening endoscopic, diagnostic APR-DRG= 720.2 - Septicemia & disseminated infections * no change to DRG SIW =.8646 Reimb= $9,880.27* no impact RRA, Inc. 34
Coding Clinic Advice DRG Impact Example: MRSA Sepsis, with MRSA Pneumonia, Endotracheal intubation with >96hrs Mechanical ventilator with Rt lower lung lobe BAL (lung) Coding Clinic, First Quarter 2017, page 51, Correction notice MS- DRG A4102 - Sepsis due to Methicillin resistant Staphylococcus aureus J15212 - Pneumonia due to Methicillin resistant Staphylococcus aureus 0BH17EZ- Insertion ET 5A1955Z- Respiratory Ventilation > 96 hrs 0B9J8ZX - Drainage of left lower lung lobe, via natural or artificial opening endoscopic, diagnostic MS-DRG= 853 - Infectious & parasitic diseases w O.R. Procedure w mcc SIW = 5.1097 Reimb= $ 64,470.37 Other DRG results With no BAL procedure: The BAL changes to with OR sepsis DRG down -9K 870 - Septicemia or severe sepsis w mv >96 hours = $ 73,471.70 APR-DRG A4102 - Sepsis due to Methicillin resistant Staphylococcus aureus J15212 - Pneumonia due to Methicillin resistant Staphylococcus aureus 0BH17EZ- Insertion ET 5A1955Z- Respiratory Ventilation > 96 hrs 0B9J8ZX - Drainage of left lower lung lobe, via natural or artificial opening endoscopic, diagnostic APR-DRG= 720.2 - Septicemia & disseminated infections * no change to DRG SIW =.8646 Reimb= $9,880.27 * no impact RRA, Inc. 35
Coding Clinic Advice DRG Impact Example: Acute hypoxic respiratory failure, due to MRSA Pneumonia with Rt lower lung lobe BAL, Endotracheal intubation with >96hrs Mechanical ventilator Coding Clinic, First Quarter 2016, page 26, Original advice No O.R. impact MS- DRG J15212 - Pneumonia due to Methicillin resistant Staphylococcus aureus J9601 - Acute respiratory failure with hypoxia 0B9B8ZX - Drainage of left lower lobe bronchus via natural or artificial opening endoscopic 0BH17EZ- Insertion ET 5A1955Z- Respiratory Ventilation > 96 hrs MS-DRG= 207 - Respiratory system diagnosis w ventilator support >96 hours SIW = 5.3364 Reimb= $67,065.56 APR-DRG J15212 - Pneumonia due to Methicillin resistant Staphylococcus aureus J9601 - Acute respiratory failure with hypoxia 0B9B8ZX - Drainage of left lower lobe bronchus via natural or artificial opening endoscopic 0BH17EZ- Insertion ET 5A1955Z- Respiratory Ventilation > 96 hrs APR-DRG= 130.1 - Respiratory system diagnosis w ventilator support 96+ hours SIW = 2.9856 Reimb= $29,481.79 RRA, Inc. 36
Coding Clinic Advice DRG Impact Example: Acute respiratory failure, with MRSA Pneumonia with Rt lower lung lobe BAL, Endotracheal intubation with >96hrs Mechanical ventilator Coding Clinic, First Quarter 2017, page 51, Correction notice O.R. impact on DRG MS- DRG J15212 - Pneumonia due to Methicillin resistant Staphylococcus aureus J9601 - Acute respiratory failure with hypoxia 0BH17EZ- Insertion ET 5A1955Z- Respiratory Ventilation > 96 hrs 0B9J8ZX Drainage of left lower lung lobe, via natural or artificial opening endoscopic, diagnostic MS-DRG= 166 - Other resp system O.R. Procedures w mcc SIW = 3.5562 Reimb= $ 46,686.34 20K APR-DRG J15212 - Pneumonia due to Methicillin resistant Staphylococcus aureus J9601 - Acute respiratory failure with hypoxia 0BH17EZ- Insertion ET 5A1955Z- Respiratory Ventilation > 96 hrs 0B9J8ZX Drainage of left lower lung lobe, via natural or artificial opening endoscopic, diagnostic APR-DRG= 130.1 - Respiratory system diagnosis w ventilator support 96+ hours SIW = 2.9856 Reimb= $ 29,481.79 No Impact RRA, Inc. 37
Coding Clinic Advice Insertion access/infusion line(s). Peripherally Inserted Catheter A peripherally inserted central catheter (PICC) is inserted into a peripheral vein in the arm, such as the cephalic vein, basilic vein or brachial vein, and then advanced toward the heart through larger veins, until the tip rests in the distal superior vena cava or cavoatrial junction. A PICC line inserted into the right arm with the tip resting in the superior vena cava or cavoatrial junction is coded as 02HV33Z, Insertion of infusion device into superior vena cava, percutaneous approach. Central Venous Catheter Central venous catheters (CVC) are inserted into larger, deeper veins such as the subclavian, jugular, or femoral veins. The catheter is then advanced into the right atrium or superior vena cava. The femoral vein is used infrequently because of concern over deep vein thrombosis (DVT). A central venous catheter inserted via the left internal jugular vein with the tip resting in the right atrium is coded as 02H633Z, Insertion of infusion device into right atrium, percutaneous approach. RRA, Inc. 38
Coding Clinic Advice DRG Impact Procedures on Tubular structuresinsertion of central line Example: Sepsis E. Coli, Interventional radiology placement of Infusion, rt side upper artery puncture with catheter tip device placed into the Right Atrium NOTE: SVC/Atrial junction is coded to SVC. MS-DRG A4151Sepsis due to Escherichia coli [E. coli] 02H633Z- Insertion infusion device right atrium, percut MS-DRG= 872 - Septicemia or severe sepsis w/o mv >96 hours w/o mcc SIW = 1.0283 Reimb= $ 17,747.65 No impact APR-DRG A4151Sepsis due to Escherichia coli [E. coli] 02H633Z- Insertion infusion device right atrium, percut* APR-DRG= 710.1 - Infectious & parasitic diseases including HIV w O.R. procedure SIW = 1.0487 Reimb= $ 11,581.66 *Impacts as an O.R. procedure 5K RRA, Inc. 39
Coding Clinic Advice DRG Impact Root operation for Dry Spinal Tap Coding Clinic Advice Coding Clinic First Quarter 2017 Question: A patient presented for diagnostic lumbar puncture due to subarachnoid hemorrhage. The needle was advanced into the lumbar subarachnoid space. Despite attempts, no cerebrospinal fluid could be obtained. What is the procedure code assignment for the procedure? Answer: Assign the following procedure code: 00JU3ZZ Inspection of spinal canal, percutaneous approach Inspection can be coded when attempted drainage is not completed, and no other root operation is performed. Drainage would not be coded when the full definition for the root operation, taking or letting out fluids and/or gases from a body part, is not met during the procedure. Official Coding Guidelines PCS 2017 Discontinued procedures B3.3 If the intended procedure is discontinued, code the procedure to the root operation performed. If a procedure is discontinued before any other root operation is performed, code the root operation Inspection of the body part or anatomical region inspected. RRA, Inc. 40
Coding Clinic Advice DRG Impact Example: Sepsis, severe headache, neck stiffness possible bacterial meningitis. Spinal tap performed, dry tap no fluid obtained. MS- DRG A419- Sepsis unspecified R51 - Headache 00JU3ZZ - Inspection of spinal canal, percutaneous approach MS-DRG= 872 - Septicemia or severe sepsis w/o mv >96 hours w/o mcc SIW = 1.0283 Reimb= $ 17,747.65 No Impact APR-DRG A419- Sepsis unspecified R51 - Headache 00JU3ZZ - Inspection of spinal canal, percutaneous approach* APR-DRG= 710.1 - Infectious & parasitic diseases including HIV w O.R. procedure SIW = 1.0487 Reimb= $ 11,581.66 *Impacts as an O.R. procedure 5K RRA, Inc. 41
Plan to educate each September for Official Coding Guideline changes/additions Install all new electronic resources, guidelines, coding clinic advice, Key Take Away Points grouper versions, rate s and coding updates promptly Plan to educate quarterly for each new Coding Clinic quarterly publication release Utilize the updates and guideline changes to identify product line and internal trends impacted Bench mark trends for top 10 DRGs, procedures, CC/MCC to validate and test new coding guidelines Incorporate quarterly validation into your overall internal coding quality and compliance plan Proactive oversite of changes will minimize external audit denials RRA, Inc. 42
Contact information: Deborah@rra-inc.com RRA, Inc. 43
References https://www.cms.gov/medicare/coding/icd10/downloads/2017- ICD-10-CM-Guidelines.pdf https://www.cms.gov/medicare/coding/icd10/downloads/2017- Official-ICD-10-PCS-Coding-Guidelines.pdf https://www.cms.gov/icd10manual/version34-fullcodecms/fullcode_cms/p0387.html RRA, Inc. 44