Most Responsible Diagnosis

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Most Responsible Diagnosis Complexity Coding

• HS317b - Coding Classification of Health
  Information

2

MCC
4 Complexity levels
CMG

RIW
3
Complexity Levels

• PLX 1 - no complexity
• PLX 2 - complexity related to chronic conditions
• PLX 3 - complexity related to serious or
  important conditions
• PLX 4 - highest complexity - complexity related
  to life-threatening conditions
• PLX 9 - complexity age split are inherent in
  the CMG so no need for further PLX

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Complexity 9

• Assigned to
• MCC 14 Pregnancy Childbirth
• MCC 15 Newborns Neonates
• MCC 19 Mental Diseases Disorders
• MCC 24 HIV Infections
• MCC 25 (CMG 651-659, 674-679 only) Significant
  Trauma
• MCC 99 Ungroupable Data

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Complexity Assignment

• Identifies other diagnoses (other than most
  responsible diagnosis) which may prolong the
  length of stay and/or the need for more costly
  treatment.

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Resource Intensity Weight

• Resource total hospital service cost including
  fixed and variable components
• Intensity the amount of service utilized
• Weight relative value of each case compared to
  the average case which is the value of 1

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Resource Intensity Weight (RIW)

• A statistical cost which recognizes that not
  every patient consumes the same resources during
  their stay in hospital.
• Resources can differ due to
• Differences in LOS
• Types of resources used (medical/surgical)
• Nursing intensity, etc.

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Categories of patients

• Typical patient who receives a fully successful
  course of treatment in a single institution and
  is discharge when they no longer require the
  services of an acute care hospital
• Atypical patient who exhibits a different
  pattern of care either because they do not
  complete a successful course of treatment in a
  single hospital visit or because the LOS is
  greater than the statistical trim point for
  CMG/Plx Level (examples sign-outs, death,
  transfers, long stay outliers)

9
Comorbidity conditions

• Identify other diagnosis to indicate 5 complexity
  levels - only 465 codes that impact complexity
  level
• Significantly impacts complexity levels and RIWs

10
Comorbidities

• All conditions that coexist at the time of
  admission or develop subsequently demonstrate
• Significantly affects the treatment received
• Requires treatment beyond maintenance of the
  pre-existing condition
• Increases the LOS by at least 24 hours

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How to determine significance?

• Documented evidence in physicians
  notes/discharge summary that
• Clinical evaluation/consultation document a new
  or amended course of treatment
• Therapeutic treatment/intervention with a code
  assignment of 50 or greater from Section 1 of
  CCI
• Diagnostic intervention, inspection or biopsy
  with a code assignment from Section 2 of CCI
• Extended the LOS by at least 24 hours

12
Post procedural condition

• Documented by physician as a complication of the
  procedure
• Present at discharge
• Persist post-procedurally for at least 96 hours

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Valuable tools for coding

• Nurses notes
• Pathology reports
• Laboratory reports
• Autopsy reports
• Medication profiles
• Radiological investigations
• Nuclear imaging
• etc

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Comorbid Conditions Identification

• A one digit number or letter to identify the
  relationship of the diagnosis to the patients
  stay in hospital
• Diagnosis type 1, 2, 3, 4, 6, 9, 0, W, X, Y

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Diagnosis type 1

• Pre-Admit Comorbidity
• A condition that existed pre-admission
• Satisfies the requirements for determining
  comorbidity

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Diagnosis type 2

• Post-admit Comorbidity
• A condition that arises post-admission
• Satisfies the requirements for determining
  comorbidity

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Diagnosis Type 3

• Secondary Diagnosis
• A condition or diagnosis which may or may not
  have received treatment
• Does not satisfy the requirements for determining
  comorbidity
• Some codes require a diagnosis type 3

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• Diagnosis type 3 conditions are coded if they are
  listed on the
• Front sheet
• Discharge summary
• Death certificate
• History physical
• Pre-operative anesthetic consult

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Diagnosis Type 6

• Proxy MRDx
• It is assigned to an asterisk code, the
  manifestation in a dagger/asterisk convention
  when it fulfills the requirements stated in the
  definition of MRDx.
• Can only apply diagnosis type 6 to the second
  line of a diagnosis field of the abstract.
• Only one asterisk code is allowed a diagnosis
  type 6 per encounter.

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Diagnosis type W, X, or Y

• Service Transfer Diagnosis
• A diagnosis associated with the
  first/second/third service transfer
• Recording the days spent under another patient
  service

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Diagnosis Type 4 Morphology Codes

• Morphology codes derived form ICD-O codes
  describing the type and behaviour of neoplasm

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Diagnosis type 9 External Cause of Injury code

• Mandatory to use with codes in the range of
  S00-T98, injury, poisoning and certain other
  consequences of external causes
• Category U98., Place of Occurrence
• Mandatory with codes in the range of W00-Y34
• Exception Y06 Y07

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Diagnosis Type 0

• Use to distinguish babies born via caesarean
  section from those born vaginally
• Application code range is Z38. Liveborn infants
  according to place of birth P03.4 Fetus and
  newborn affected by caesarean delivery

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Goals for Coding

• To distinguish between the diagnosis type
  categories used in DAD coding/abstracting
  correctly apply them
• To interpret apply the Canadian Coding
  Standards for ICD-10-CA CCI
• To recognize the importance of consistent
  application of standards to data quality

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Abstract with CMG MCC Assignment
Plx Level
Plx to MCC or CMG
9
Yes
Complexity not applicable
Yes
4
Complexity related to life threatening
Vent gt 96 hours
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Presence of Service Transfer or CC Diagnoses
N0
1
No Complexity
Eliminate Duplicate Dx
Assign Grades to Each Dx
Assign Plx Level