Title: MS-DRGs
1MS-DRGs
- Kiwi-Tek Webinar
- Session 2
- August 2009
- Joy King, RHIA, CCS
- Karen Scott, MEd, RHIA, CCS-P, CPC
2Pneumonia
- An acute inflammation of alveoli terminal lung
spaces due to infection - S/S malaise, fever, dyspnea, cough, sputum
production, pleuritic chest pain, confusion
and/or obtundation w/o respiratory symptoms - Findings infiltrate on CXR (gold standard), RR gt
25, HR gt 100, rales, crackles, rhonchi, dullness
to percussion, decreased breath sounds
3Pneumonia
- Community-Acquired (CAP) infection in patient
who was not hospitalized or residing in LTC 14 or
more days prior to infection - Hospital-Acquired (HAP) infection 48 hrs or more
after hospitalization in patients w/ no previous
infection. Early onset w/in 1st 4 days of
hospital stay, late onset after 4 days - Vent-Associated (VAP) occurs 48-72 hrs after
endotracheal intubation - Healthcare-Associated (HCAP) develops w/in 90
days of a gt 2-day stay or in NH or LTC resident
or w/in 30 days of IV abx tx, chemo or wound
care or following clinic or HD visit or contact
w/ multi-drug resistant (MDR) pathogens
4Healthcare-Associated Pneumonia (HCAP)
- Srep pneumoniae (gram )
- Drug-resistant Strep pneumoniae (DRSP)
- Hemophilus influenzae (gram -)
- Moraxella catarrhalis (gram -)
- Staph aureus (gram )
- Klebsiella pneumoniae (gram -)
- MRSA (gram )
- Acinetobacter (gram -)
- Initial Tx broad-spectrum abx--all HCAP patients
presumed to be infected w/ MDR pathogens,
considered high-risk, usually admitted
5Pneumonia
- Simple Pneumonia Streptococcal, Pneumococcal, H.
flu, Mycoplasmaif patient only on Levaquin,
Rocephin or Zithromax, probably NOT complex - Viral Pneumonia 480.x (now an MCC)mucopurulent
sputum, pleuritic CP, neg bacterial smears,
interstitial pneumonia on CXR, chills, rales,
hypotension, headachetx w/ Amantadine, O2,
nebulizer - Complex Pneumonia Klebsiella, H parainfluenza,
Legionella, Moraxella, Pseudomonas, S. aureus,
gram -, anaerobes, aspiration, TB, fungal
6Pneumonia
- Look at organism on sputum c/s abx
- Aspiration PneumoniaClindamycin, Unasyn, Zosyn
- Gram-negativeZosyn, Gentamicin, Tobramycin,
Amikacin, Ceftazidine, Ciprofloxacin, Primaxin,
Tygacil - S. aureus (including MRSA)Clindamycin, Unasyn,
Zyvox, Vancomycin - EnterococciZyvox, Vancomycin
7Aspiration Pneumonia
- MD must link aspiration pneumonia
- Most commonly in rt lower lobe (gt 50)
- S/S sudden onset dyspneaCXR findings,
leukocytosis fever may lag behind silent
aspiration often cause of recurrent asthma, COPD
or CHF nocturnal wheezing non-cardiogenic
pulmonary edema - Risk factors GERD, elderly, stroke w/ dysphagia,
other swallowing disorders
8MS-DRG Options
- Simple Pneumonia (DRG 89, r.w. 1.0376)
- MS-DRG 193 w/ MCC 1.4327
- MS-DRG 194 w/ CC 1.0056
- MS-DRG 195 w/o CC 0.7316
- Complex Pneumonia (DRG 79, r.w. 1.6268)
- MS-DRG 177 w/ MCC 2.0393
- MS-DRG 178 w/ CC 1.4983
- MS-DRG 179 w/o CC 1.0419
9Pneumonia
- Coding Issues
- Lack of documentation of cause
- Co-existing conditions, such as sepsis, on
admission and lack of MD documentation to
determine sequencing as PDx or secondary dx - Symptoms overlapping w/ other forms of
respiratory disease such as acute bronchitis and
COPD
10CAD Related Conditions
- Chest Pain document causes, such as chest wall
pain, costochondritis, GERD, cholelithiasis
esophagitis, CAD, Syndrome X, coronary vasospasm,
pulmonary embolus, aortic dissection - Stable Angina
- I none w/ inactivity, present if strenuous
413.9 - II early onset w/ regular activity 413.9
- III marked limitation of activity 413.9
- IV angina at rest (angina decubitus) 413.0 (CC)
11CAD Related Conditions
- Unstable Angina occurs at rest lasts gt 20 min
OR severe, described as flank pain, starting w/in
past month, OR crescendo pattern411.1 (CC) - Non-Q wave MI elevation of cardiac enzymes
(troponin 1 gt 0.4 mg/dL) in setting of angina
symptoms, EKG changes, or other cardiac
manifestations410.71 (MCC) - MI 410.x (MCC)look for EKG changes, heparin,
elevated troponin levelif admitted to r/o MI,
document if patient had acute MI
12Acute MI
- New universal definition Myonecrosis
- Elevation of troponin gt 99th percentile of normal
- MImyonecrosis secondary to ischemia
- MI myonecrosis at least 1 below
- Symptoms
- Ischemic ST or T wave changes
- New LBBB
- New Q waves
- PCI-related marker elevation or imaging for new
myocardial loss
13MI Complications
- Cardiogenic shock V tach
- Bilateral BBB coronary dissection
- Trifascicular block respiratory failure
- PAT cardiac arrest
- Pericarditis V flutter/fib
- Accelerated HTN pulmonary embolus
- 2nd degree Mobitz I block
- 3rd degree AV block other arrhythmias
14Arrhythmias
- A fib 427.31 not a CC
- A flutter 427.32 CC rapid rhythm w/ heart rate
gt 100 if gt 120, palpitations, dizziness, syncope - A fib/flutteruse both codes
- V tach 427.1 (gt 100/min) CC abnormal rapid
heart beat w/ heart rate gt 120 if sustained,
heart failure may follow - Code if sustainednot tx if lt 30 seconds
15Arrhythmias
- V fib 427.41 MCC only if patient d/c alive
rapid irregular rhythm, usually caused by severe
myocardial damage or drug toxicity heart pumps
little or no blood death w/in minutes if tx not
immediate - V flutter 427.42 MCC
- Tx w/ cardioversion/AICD, IV lidocaine beta
blocker Amiodarone may be used to suppress V
tach or V fib
16Heart Blocks
- 426.6 SA blocknot a CC
- 426.10 unspec AV 426.11 1st degree AVnot CCs
- 416.122nd degree Mobitz II CC
- 416.132nd degree Mobitz I or Wenckebachsnot a
CCrarely tx - 426.03rd degree complete CC
- LBBBnot CCs
- RBBBonly 426.53 bifascicular 426.54
trifascicular are CCs
17Complete AV Block
- S/S lethargy, postural HTN, SOB, syncope,
dizzinessusually results from infection,
fibrosis, or scarring from MI, digitalis toxicity - Tx w/ inferior MItx w/ temporary pacer w/
anterior MItreated w/ permanent pacer
18Chest Pain MS-DRG Options
- DRG 313 Chest Pain (no split) 0.5314
- DRG 303 Atheroscl w/o MCC 0.5688
- DRG 311 Angina (no split) 0.4972
- DRG 282 Acute MI, alive w/o CC 0.8696
- DRG 204 Resp S/S (no split) 0.6548
- DRG 392 Esophagitis, GE w/o MC 0.6703
- DRG 395 Other digestive w/o CC 0.6765
- DRG 446 Dx biliary tract w/o CC 0.7231
- DRG 74 Cranial/periph nerve 0.8423
19Decubitus Ulcers
- S/S bed-ridden, paralysis, necrosis, hx injury
in DM, pressure sores, edema, blisters,
osteomyelitis, induration, cellulitis - Tx wound care orders, air bed, debridement,
frequent turning
20Decubitus Ulcers
- Stage 1 non-blanching erythema (reddened area on
skin) - Stage 2 abrasion, blister, shallow open crater,
or other partial thickness skin loss - Stage 3 full-thickness skin loss involving
damage or necrosis into subcutaneous soft tissues - Stage 4 Full-thickness skin loss w/ necrosis of
soft tissues through to the muscle, tendons, or
tissues around underlying bone. - Unstageable due to being inaccessible for
evaluation (non-removable dressings, eschar,
sterile blister, suspected deep injury in
evolution). - (Included in CC 4 Q 2008)
21Coding Pressure Ulcers
- 2 Codes required 707.0x for site/diagnosis
707.2x for stage. (Stage codes 707.23 707.24
are MCCs) - The 707.2x code for stage should follow the
707.0x code for diagnosis/site - Dont confuse 707.25 unstageable (clinical
assessment) with 707.20 stage unspecified
(documentation issue) - If the pressure ulcer progresses during the stay,
code to the highest stage
22Pressure Ulcer Stages
- Diagnosis of pressure ulcer site must be
documented by an MD to be codedcant just
document wound - The stage of the pressure ulcer can be coded from
clinicians involved in the care of the ulcer
(Wound Care RN) - If a pressure ulcer is documented as Stage 2 on
admission, but progresses to Stage 3 or 4 during
the stay, the code for highest stage should be
listed on the claim - The POA indicator for the ulcer should be Y even
if the stage has progressed during stay
23Sequencing Stage Codes
- Encoders generally sequence the codes to pull
those impacting reimbursement (MCC/CCs) into the
top 9 read by CMS - The stage codes are to be sequenced after the
diagnosis/site codes however they impact
reimbursement if Stage 3 or 4 - The coders may have to manually resequence those
within the top 9 before codes drop to the bill
(may have encoder setting to do it) - Develop a policy to clarify if that will be done
for all Stage 3 or 4 pressure ulcers, especially
if other MCCs w/ impact can fill up top 9
24GI Disorders
- Diverticulitis
- Gastric Ulcer
- Blood in Stool
- GI Hemorrhage
- Diverticulitis w/ hemorrhage
- Diverticulosis w/ hemorrhage
- Gastritis w/ hemorrhage
25Impact on Severity/Reimbursement
- Adm for COPD exacerbation w/ acute bronchitis.
Stools occult EGD confirmed gastritis. - PDx COPD exacerbation, Secondary Dx Gastritis
- MS DRG 192 COPD w/o CC/MCC r.w. 0.7254 3718
- Secondary Dx Gastritis, GI bleed
- MS DRG 191 COPD w/ CC r.w. 0.9757 5000
(1,282) - Secondary Dx GI bleed due to gastritis
- MS DRG 190 COPD w/ MCC r.w. 1.3030 6678
(2960)
26Degree of Malnutritionwww.merck.com
Measure Mild Moderate Severe
Normal Wt (nl 90-110) 85-90 75-85 lt 75
BMI (nl 19-24) 18 18.9 16 17.9 lt 16
Serum Albumin (nl 3.5-5.0) 3.1 - 3.4 2.4 3.0 lt 2.4
Serum Transferrin (nl 220-440) 201 - 219 150 - 200 lt 150
Serum Prealbumin (nl 18-45) 10-17 5-9 lt 5
27Malnutrition
- 263.0 Moderate malnutritionnot a CC
- 263.1 Mild malnutritionnot a CC
- 263.8Other protein-calorie malnutritionCC
- 263.9Unspecified protein-calorie MalnutritionCC
- 263.2Arrested developmt following
malnutritionCC - 260KwashiorkorMCC wet, swollen, edematous form
- 261Marasmus (severe malnutrition)MCC dry form,
causes wt loss depletion of fat - 262Other severe malnutritionMCC any disorder
protein-calorie nutrition other than marasmus - 799.4Cachexia (BMI lt 18.5)--CC
28Nutritional Status
- Protein-Calorie Malnutrition
- Malnutrition
- Cachexia
- BMI lt19, gt39
- Severe Malnutrition
- Severe Protein (Calorie) Malnutrition
29Malnutrition Scenario
- Pneumonia (486) Principal Diagnosis
- Protein-calorie Malnutrition, unspecified (263.9)
documented as secondary dx (CC) - Query for severity of Malnutrition per
documentation of Albumin levels of 2.1 and 2.4,
which can be indicative of Severe Malnutrition
(MCC) - Pneumonia w/ CC DRG 194, 1.0056 5,704
- Pneumonia w/ MCC DRG 193, 1.43270 8,127
30Impact on Severity/Reimbursement
- PDx Chronic Osteomyelitis Leg
- Secondary Dx Malnutrition (CC)
- MS DRG 539 r.w. 2.0287 6,905
- Secondary Dx Severe Malnutrition (MCC)
- MS DRG 540 r.w. 4.5059 10,357
- Difference of 3,452
31Impact on Severity/Reimbursement
- PDx CA colon
- Secondary Dx Malnutrition
- Procedure Bowel resection
- MS DRG 330 Major Bowel Proced w/ CC
- r.w. 2.5589 14,074
- Secondary Dx Severe malnutrition
- MS DRG 329 Major Bowel Proced w/ MCC
- r.w. 5.1666 28,416 14,342
32Electrolyte Imbalances
- Hyponatremia (276.1)CC caused by CHF,
cirrhosis, ARF, SIADH, Addisons, hypothyroidism,
diuretic, hypoaldosteronism - Hyperkalemia (276.7)not a CC caused by
acute/chr kidney failure, metabolic acidosis,
hypoaldosteronism - Complications of electrolyte imbalances include
metabolic encephalopathy, seizures, V tach
33Hyponatremia
- S/S mainly from CNS dysfunction
- Headache
- Confusion
- Stupor
- Can lead to seizures, coma death
34Altered Mental Status
- In elderly, often the only symptom of infection
such as UTI, pneumonia or sepsis on presentation - Delirium, stupor, coma, mania, confusion,
psychosis, delusions, depressive features,
hallucinations are CCs and show severity - Alzheimers is MCC if document delusional,
depressed or psychotic features - Dementiadocument cause/type
- SchizophreniaCC
- Drug withdrawalCC
35Metabolic Encephalopathy
- Synonyms Delirium (780.09not CC) or Acute
Confusional State (code 293.0 for acute
delirium acute confusional state) -- CCs - Encephalopathy Codes 348.30 348.39 MCCs
- Common Causes drugs, dehydration, infection
- Metabolic encephalopathy (348.31) due to
metabolic issues from underlying cause seen in
12-33 of patients w/ organ failure - Toxic encephalopathy (349.82) MCC, due to
drugs, usually denotes altered state of
consciousness such as delirium
36Delirium
- Acute changes in cognition fluctuating during the
day - Inattention plus
- Disturbance of consciousness (less clarity)
- or
- Altered level of consciousness or disorganized
thinking - Unlike delirium, mental disorders (dementia,
etc.) almost never cause inattention or
fluctuating consciousness
37Delirium
- 10 of elderly admitted to hospital w/
delirium15-50 experience delirium at some point
during the hospital stay - Tx correction of causeabx for infection, IV
fluids electrolytes for dehydration, etc. - Morbidity/mortality higher in patients w/
delirium when hospitalized or who develop it
during stay1 yr mortality of 35-40 (same as AMI
sepsis)
38Scenario
- Pt adm w/ AMS deliriumnot on diuretics. Na of
118, tx w/ hypertonic saline sent home on fluid
restriction. Final Dx Delirium due to
Hyponatremia - DRG Options
- 276.1 Hypo Na DRG 641 w/o MCC 0.6820
- 780.09 Delirium DRG 81 0.7104
- 253.6 SIADH DRG 645 w/o CC 0.7188
- 348.30 Met encephal DRG 71 w/ CC 1.1361
- 253.6 348.30 DRG 643 w/ MCC 1.6464
39Reflection of Severity
- Concussion or loss of consciousness
- DM, uncontrolled
- Type of anemia
- Type of angina
- Hyponatremia
- Respiratory failure
- Closed head injury
- poorly controlled DM
- Anemia
- Angina
- Na 125
- Respiratory insufficiency
40Potential Severity Queries
- BS gt 100, 200, 500, Hgb A1c gt 7.0uncontrolled
DM? - CO2 of 15query for acidosis
- ABGs w/ pH 7.32, CO2 50, PO2 60 (50/50 or 50/60
club) non-rebreather mask or BiPAP, CPAPquery
for resp acidosis if not on vent - Albumin lt 3.0 for 3 wks, prealbumin lt 16, BMI lt
17query for severe malnutrition - BMI gt 35, gt 40 w/ DM or CADmetabolic syndrome
- Elev troponin, EKG changes, on heparin, seen by
Cardiologyquery for MI - Platelets around 100,000query for
thrombocytopenia - Elev BS, on steroids and SSIhyperglycemia or DM
secondary to steroids - Chronic drug usequery for dependence
- Chronic O2 usequery for dependence
41Documentation Improvement Tips
- Use Nurses notes, Wound care notes, PT, OT, ST,
Nutritional notes to generate information for
queries - Ask Nursing to capture diagnoses when documenting
verbal orders - Ask Wound Care nurse to identify type, location,
Stage of decubitus and other wounds in the orders
co-signed by the MD and/or have the MD co-sign
Wound Care progress notes - Ask Nutrition to identify stage of malnutrition
as basis for queries and/or have them document
BMI values - NOTE BMI values can be coded from Nutrition
notes w/o MD documentation (exception per AHA)
42Physician Queries
- When
- There are specific clinical indications that
indicate the condition may be present - Documentation from different MDs
conflictsclarification should be obtained from
attending MD - Not needed when a consultant/anesthesiologist
documents additional dx or specificity from
attending - Diagnosis not mentioned after the 1st day or two
and/or treatment not consistent w/ that
diagnosis, e.g. abx discontinued - Unable to tell if a condition was POA
43Physician Queries
- How
- Develop policy guidelines on when to query
- Document specific clinical evidence from the
record, including ancillary findings, tx, etc. to
support the query - Keep questions open-ended, rather than yes or no
- Leading questionsnot based on clinical clues in
record, no reason to ask the question - Have MD document information in the PN and/or DS
if the query form will not remain in the record
44How to Query
- The process for querying physicians must be a
patient-specific process, not a general process.
- Each facility should develop a standard format
for the query form. No sticky notes or scratch
paper should be allowed. - Preferred formats facility-approved query form,
fax, secure email, secure IT messaging system,
verbal queries
45How to Query
- Multiple choices w/ checkboxes OK if ALL
clinically reasonable choices listed, regardless
of financial impact. - Should include an other option w/ line for MD
to write in - Should include an unable to determine option.
46How to Query
- If there are multiple questions for one case,
ensure that - It is clear to the physician that he/she has more
than one to respond to and - Ensure that there is sufficient room to write a
response (if it is required on the form) - E.g. IDDM w/ elevated BS documented on admission
in patient w/ renal failure - Q 1 type of DM
- Q 2 relationship of DM to renal failure
- Q 3 DM uncontrolled or controlled?
47Physician Queries
- queries WILL increase--may impact DS
- Document response to queries either in PN/DS or
on a query form that remains in the MR - POA query forms can utilize a checkbox format
which MD initials or signs - The MD query will NOT include a U option, only a
W for clinically undetermined - Hold claims w/ outstanding POA queries for
response, since this is a billing
requirementwill impact DNFB
48Pneumonia vs. AMI Scenario
- HP, Admit order state R/O Pneumonia
- CXR neg for infiltrate, no elev WBC
- Elevated troponin levels cardiac enzymes,
abnormal EKG, transferred to larger facility on
1st day of stay - No DS on chart, no progress notes
- Case coded to Pneumonia (486) as Principal
Diagnosis based on HP Admit Order - Query?
- Pneumonia DRG 195, 0.7316 4,150
- AMI DRG 282, 0.8696 4,933
49Acute Renal Failure Scenario
- Patient presented with altered mental status, BUN
169, Cr 4.8, Na 172. PN 10/19 states, admitted
with dehydration, azotemia hyponatremia. The
DS states patient treated w/ IV fluids, azotemia
resolved, still stuporous. - Hyponatremia (276.1) coded as Principal Diagnosis
- Query?
- Hyponatremia DRG 641, 0.6820 3,869
- Acute Renal Failure DRG 683, 1.1304 6,412
50AMS Scenario
- NH patient presents to ED w/ 2-day hx decreased
oral intake AMS. CXR shows no infiltrates. WBC
15,000, Na 118, U/A spec gravity of 1.030, BUN
58, Cr 1.4. - Admitting dx is AMS renal insufficiency. No
further mention of renal status in chart.
Patient tx w/ IV fluids and IV abx. DS lists
Pneumonia Dehydration. - Query?
51Query Impacts
- As documented Pneumonia, Dehydration, Renal
Insufficiency DRG 195 4,150 - W/ query for Acute Renal Failure (MCC)
- DRG 193, 8,127
- W/ query for type of Pneumonia as PDx
- Gram negative Pneumonia, Dehydration, Renal
Insufficiency DRG 179, 5,910 - w/ query for Hyponatremia (CC) DRG 178 8,499
or - w/ query for Acute Renal Failure(MCC) DRG
177 11,568 7,418 difference
52Questions?
- Contact Information
- Joy King Consulting, LLC
- jkinginc_at_charter.net
- (205) 612-4471