Understanding

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Understanding Using APR DRGs Present On
Admission
MHIMA Sept 15, 2006
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Session Topics

• What is severity and risk adjustment?
• Attributes of the APR DRG Classification System
• Present On Admission (POA)
• Implications for the HIM professional

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Severity and Risk Adjustment
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There is a growing demand for increased precision
in classifying patients to

• Improve healthcare payment systems
• Support clinical and quality initiatives that
  improve patient care

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Purpose of Severity and Risk Adjustment

• To quantify differences in demographic and
  clinical risk factors found among patients
  treated in hospitals
• To obtain fair and accurate statistical
  comparisons between disparate populations or
  groups
• Clinical outcomes
• Mortality
• Complications
• Utilization measures
• Length of Stay
• Cost

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3M APR DRG Classification System
MDC/APR-MDC
Subdivide each APR DRG into subclasses

• Four Severity of Illness Subclasses
• Minor
• Moderate
• Major
• Extreme

• Four Risk of Mortality Subclasses
• Minor
• Moderate
• Major
• Extreme

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APR-DRGs Are A Categorical Clinical Model

• APR-DRGs are a clinical model that has been
  extensively refined with historical data
• Different clinical models are developed for 355
  different types of patients
• Clinical models verified with data
• Final decisions were always clinical

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Underlying Principles of theAPR DRG
Classification System
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SOI and ROM are Independent
The severity of illness and risk of mortality
subclass are calculated separately and may be
different from each other.
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APR-DRG Subclasses

• The base APR-DRG
• Two Subclasses
• Severity of Illness (SOI) the extent of
  physiologic decompensation or organ system loss
  of function
• Risk of Mortality (ROM) likelihood of dying
• Four Subclass Values
• 1 is Minor
• 2 is Moderate
• 3 is Major
• 4 is Extreme
• Subdivision of 314 base APR-DRGs into four
  subclasses plus two error DRGs (not subdivided)
  equals (3144)21,258 APR-DRGs

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Three Phases to Determine SOI/ROM Subclass

• Phase 1 Determine the SOI/ROM level of each
  secondary diagnosis
• Phase 2 Determine the base SOI/ROM subclass of
  the patient based on all the SDXs
• Phase 3 Determine the final SOI/ROM subclass of
  the patient by incorporating the impact of the
  PDX, age, OR procedure, non-OR procedures,
  multiple OR procedures, and combination of
  categories of SDXs

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Summary of APR-DRGs
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Do Severity and Risk Adjustment Really Make a
Difference?
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Do Severity and Risk Adjustment Really Make a
Difference?
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Using APR-DRG Information at the Point of Coding

• Complete coding
• To obtain accurate credit for the clinical
  complexity of your patient mix it is imperative
  that you
• Code all diagnoses that meet the UHDDs coding
  guidelines
• Dont stop when payment criteria or form limits
  are met
• Understand which sdxs are driving APR Assignment
• Understanding the effects of dataset truncation
• Resequencing to assure accurate SOI and ROM

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Common Documentation Issues
Unable to Code
Acceptable to Code
LUL Infiltrate
LUL Pneumonia
Hgb 5.2 Transfused
Acute or Chronic Blood Loss Anemia
Emaciated Total Protein/Albumin Low Nutrition
Malnutrition
Supplements Started
ABG 7.22/68/44 Will Treat Accordingly
Respiratory Failure, Acidosis, Alkalosis, Etc.
Will Rehydrate Patient
Dehydration
BP 70/40 on Dopamine for Support
Shock
Cardiac Enzymes Elevated EKG Positive
Acute MI
No Overt CHF Will Continue Lasix and Lanoxin
Compensated CHF
Unable to Void Cathed for 600 cc
Urinary Retention
Sputum Gram Stain with Large Amount Gram-
Questionable Gram-Negative Pneumonia
Negative Rods Will Cover with Rocephin
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Resequencing Before
10th Position
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Resequencing After
2nd Position
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Present on Admission

• Meeting New Requirements
• Bob Trocchi
• Territory Sales Leader
• 3M HIS

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What is the Present on Admission (POA)?

• A flag that identifies all ICD-9-CM diagnosis
  codes that were present when the patient was
  admitted for care
• Applied to principal diagnosis and all secondary
  diagnoses
• Based on conditions known at time of admission
• Includes conditions clearly present but not
  diagnosed until after admission took place
• Present at the time order for inpatient admission
  occurs
• Conditions that develop during an outpatient
  encounter including emergency department

Source National Uniform Billing Committee (NUBC)
UB-04 Data Specification Manual Third edition
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Purpose

• POA is used as a baseline for Hospital Clinical
  Outcomes reporting.
• Create a method to identify potentially
  preventable complications from those diagnoses
  not labeled as present on admission
• P4P
• POA is used to identify hospital acquired
  complications.
• Absence of POA
• To allow only those diagnoses as designated as
  present on admission to be used for assessing
  risk of incurring complications.

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Deficit Reduction Act (DRA)

• DRA requires the present on admission (POA)
  indicator for all diagnoses reported on the UB-04
  claim beginning in October of 2007

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Massachusetts POA Requirements

• Massachusetts Division of Health Care Finance and
  Policy 114.1 CMR 17.00
• The amendments are effective October 1, 2006, but
  based on testimony submitted, the Division will
  delay error edits for the new requirements until
  January 1, 2007. Below is a summary of the
  changes
• Condition Present on Admission/Visit Indicator
  for all diagnosis
• Massachusetts Division of Health Care Finance
  and Policy July 20, 2006 Memorandum Summary of
  Adopted Amendments to 114.1 CMR 17.00
  Requirement for the submission of Hospital Case
  Mix Charge Data

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Process Issues with POA

• Coding - to identify POA from documentation
• Documentation Improvement
• Included with UB04
• March and May of 2007
• Interfaces
• HIS vendors
• FIs
• Claims Clearing Houses

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Financial Ramifications of POA

• Starting Oct. 1, 2008, Medicare will identify at
  least 2 infection complications that will NOT be
  included in the DRG calculation if they are not
  POA
• Absence of POA indicates the infections were
  acquired in the hospital.
• May move the DRG from with CC to without CC.
• Reduces the payment when moved to lower DRG

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Hypothetical Case Example
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HIM System Requirements

• POA flag designation for all codes
• Edit for absence of POA flag
• POA defaults for V-Codes Not Applicable.
• Integration of POA into your patient record and
  UB 04
• Logic to identify possible incorrect POA
  assignment
• Management tools to monitor accuracy and
  compliance

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The Detail

• Y Yes, present on admission
• N No, not present on admission
• U No information in the record
• W Clinically undetermined
• All above determined from the documentation in
  the record
• E Exempt from POA reporting
• List of exempt from NUBC
• UB-04 has this field blank
• E will map to blank on export for billing purposes

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Possible Management Reports
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