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Guest Post: ICD-10 delay provides CDI teams time to find hidden documentation solutions

kelli(new photo)

Kelli Estes

Taming the ICD-10 Extraneous Query Beast!

By Kelli Estes, RN, CCDS

Whether ICD-10-CM/PCS implementation is six or 18 months away, the code set expanding from 14,000 to 73,000 codes will create a query volume of epic proportion if we don’t bring things down to a 10,000-foot view and get some much needed perspective. It is simply not the intent of a CDI program to query providers for everything from soup to nuts considering such code volumes.

CDI specialists cannot possibly be productive if they are expected to be the gatekeeper for capturing all clinical documentation drilling down to the deepest level of ICD-10 specificity with an exponential growth in code volume. It just won’t happen in the real world.

I think we have to remember ICD-9-CM already provides “some” specificity in certain conditions that many physicians never tap into resulting in the use of unspecified codes, as things currently stand today. There will still be unspecified codes available in ICD-10. While I am certainly not suggesting we brush off the urgent need for being more specific, I do caution against getting stuck in some apocalyptic thought process that workflow will gridlock once ICD-10-CM/PCS goes live in all hospitals across the country. There will still be a learning curve that lingers after the “go live” date for ICD-10.  We prep and plan, but we have to actually “go there” before we can get a realistic grasp on all of this.

CDI Tip: Besides educating providers with issues common to their practice, we need to also take a collaborative approach and start developing smart assessment tools to be used within or as an adjunct to the EHR (electronic health records). This will help providers improve documentation specificity pro-actively by providing choices that lead to the necessary words for depicting a really accurate clinical picture useful for ICD-10 code selection.

For example, the following choices are necessary for drilling down to the most specific fracture code:

  • Traumatic, Pathologic, Stress
  • Anatomical specificity
  • Laterality:  Right, Left
  • Open, Closed
  • Displaced, Nondisplaced
  • Initial encounter, subsequent encounter, sequelae
  • Gustilo-Anderson Fracture Scale

Changes to note from ICD-9-CM to ICD-10-CM include:

  1. Fractures not indicated as displaced or non-displaced in documentation will be coded as displaced
  2. Fractures not indicated as closed or open in documentation will be coded as closed

With the delay of ICD-10-CM/PCS implementation it only makes sense for CDI teams to embrace the additional time to fine tune strategies for educating providers and develop useful tools to enhance documentation improvement. Learn ICD-10-CM/PCS now. Practice ICD-10 CDI now. That way, when everybody else is scrambling at the last minute, you’ll be ready.

Editor’s Note: Estes has spent more than a decade as a clinical documentation specialist and consultant, presently with DCBA Inc., in Atlanta. She holds the CCDS certification through ACDIS and was in the first group of participants to sit for the exam. Since joining DCBA in 2005, Kelli has assisted with project management in dozens of CDI program implementations. She is highly skilled in the overall process of CDI program start-up and enjoys guiding the decision-making required to implement and sustain longevity in any viable program. Estes has also been involved in CDI program follow-up assessments and has written several articles for DCBA’s monthly newsletter, CDI Monthly, where this article was originally published. To subscribe to CDI Monthly, click here.

Use PEPPER to identify problematic MS-DRGs and target CDI opportunities

Laura Legg

Laura Legg

By Laura Legg, RHIT, CCS

Some MS-DRGs are more complex and prone to error than others. What can facilities do to identify and manage these MS-DRGs that are prone to error?

One method for identifying error-prone MS-DRGs is through use of the Program for Evaluating Payment Patterns Electronic Report (PEPPER) report. The PEPPER report provides organizations with insight into potential vulnerabilities that may result in denied claims and recoupment. PEPPER short-term acute care hospital targets include:
  • Short stays
  • Three-day stays
  • Error-prone DRG assignments
Recovery Auditors also focus on DRG assignments and often request records for error-prone DRGs.
Facilities can use PEPPER data to identify outliers and act upon them. Data found in the PEPPER report is based on paid Medicare claims and has a ranking system that includes all organizations receiving Medicare payments. With this information, outliers can be identified. Medicare also provides a quarterly analysis of hospital-specific Medicare inpatient claims that are vulnerable to improper payment, including potential overpayments and underpayments.
Want to learn more about how to use PEPPER at your facility, check out these additional resources:
Editor’s Note: Laura Legg is director of health information management for Healthcare Resource Group in Renton, Washington. Email her at LLegg@hrgpros.com. She has more than 25 years of experience in HIM and has served as an HIM Manager/Director for several acute care/critical access hospitals and a major hospital system. This article originally published on JustCoding.com.

Book Excerpt: Understanding query opportunities is like listening to the M.U.S.I.C

The Physician Advisor's Guide to CDI.

The Physician Advisor’s Guide to CDI.

The diagnoses in each major diagnostic category (MDC) correspond to a single organ system or etiology and, in general, are associated with a particular medical specialty. MDC 1 to MDC 23 are grouped according to principal diagnoses. Patients are assigned to MDC 24 (Multiple Significant Trauma) with at least two significant trauma diagnosis codes (either as principal or secondaries) from different body site categories. Patients assigned to MDC 25 (HIV infections) must have a principal diagnosis of an HIV Infection or a principal diagnosis of a significant HIV related condition and a secondary diagnosis of an HIV Infection.

MDC 0, unlike the others, can be reached from a number of diagnosis/procedure situations, all related to transplants. This is due to the expense involved for the transplants so designated and because these transplants can be needed for a number of reasons which do not all come from one diagnosis domain. DRGs which reach MDC 0 are assigned to the MDC for the principal diagnosis instead of to the MDC associated with the designated DRG.

Of course, many different conditions can take place at the same time or have underlying causalities. Consider the pneumonic M.U.S.I.C., which you may have heard before, used as a reminder to document the:

  • M for Manifestation: e.g., sepsis, heart failure, chest pain, angina
  • U for Underlying cause or pathology: e.g., UTI, alcoholic cardiomyopathy, GERD, coronary atherosclerosis
  • S for Severity or specificity: e.g., severe sepsis, diabetes out of controlled, systolic or diastolic heart failure
  • I for Instigating or precipitating causes: Indwelling Foley cath, NSAID use, carbon monoxide poisoning
  • C for Consequences or complications: Septic shock, diabetic neuropathy

When given a diagnosis, place it one of these categories and then look for the other four, linking them with terms such as “due to,” “resulting in,” and the like.

Let’s follow this process using the example of chest pain

  • Manifestation: Describe the nature of the pain such as pleuritic or “with respiration”, angina, heartburn, biliary colic, radicular

- Note that phrases such as musculoskeletal, chest wall, atypical pain do not change the DRG

  • Underlying cause: Angina pectoris (as an example)

- Coronary atherosclerosis or thrombosis, coronary spasm, hypertrophic cardiomyopathy, complication of coronary stent or previous CABG, etc.

- Note that the code for coronary syndrome X was removed from ICD-10

  • Severity or specificity: Stable angina, accelerated angina (a complication/comorbidity [CC]), myocardial infarction (manifested by elevated troponins, a major complication/comorbidity [MCC])

- Note that the code for angina decubitus was removed from ICD-10

  • Instigating or precipitating causes: Cocaine abuse, trauma, anemia, hyperthyroidism, atrial fibrillation, accelerated or malignant hypertension
  • Consequences or complications: Ventricular tachycardia, shock, acute systolic heart failure due to “stunned myocardium”

Now let’s look at another example of how one might document the condition of altered mental status, again using the M.U.S.I.C. pneumonic.

  • Manifestation: Dementia, delirium, psychosis, stupor, coma

- Note that the phrase unresponsive does not have a code

  • Underlying cause: Various encephalopathies such as stroke, Transient Ischemic Attack (TIA), Alzheimer’s disease, Lewy-body dementia, encephalitis
  • Severity or specificity: Correlates with manifestation and underlying cause

- Note that acute states (e.g., acute delirium) are more likely to be CCs

  • Instigating or precipitating causes: Drug toxicity (document whether the drug was an overdose or not properly taken as prescribed), cerebral embolus due to atrial fibrillation
  • Consequences or complications: Acute respiratory failure, syndrome of inappropriate antidiuretic hormone secretion (SIADH) leading to hyponatremia resulting in a metabolic encephalopathy
Editor’s Note: This excerpt comes from The Physician Advisor’s Guide to Clinical Documentation Improvement by Trey La Charité, MD, and  James S. Kennedy, MD, CCS, CDIP.

TBT: Four tips to tackle multi-facility CDI management

What lesson learned do you have to share? Your peers are waiting to hear your insight. Submit your ideas for the 2014 ACDIS National Conference now.

Are you a multi-facility CDI manager? What advice would you give to someone expanding their CDI program to other network hospitals?

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We thought we’d pick up on the theme and occasionally go back into our CDI archives to highlight some salient CDI tid-bit.  Today, we’ve chosen this July 2012 article.

It’s Tuesday. For some CDI program managers that means jumping in the car and driving an hour or more to another hospital in their system to make rounds with CDI specialists there. For some, it’s a routine that happens at least once a week; for others, once a month. Although the requirements of managing CDI programs and their staff at multi-facility hospital systems differ depending on a variety of factors, try the following four best practices for success:

  1. Standardize policies and procedures; then fine-tune for differences
  2. Communicate consistently across hospitals
  3. Know your staff
  4. Use available resources

Meg McGill, RHIA, corporate director for HIM at Methodist Le Bonheur Healthcare in Memphis, Tenn., manages 19 CDI specialists across seven hospitals. In the beginning, McGill’s primary role related to governing the overall direction of the healthcare system’s CDI efforts.

Each specialist reports directly to either the chief medical officer or performance improvement director at their facility and secondarily to McGill, whose primary job is to communicate CDI program data and effectiveness to facility and system management, she says. After little more than a year, Methodist Healthcare was ready to “take the program to the next level,” says McGill.

“We had to take a step back and take a deep breath to see where we wanted this program to go and how to get there.” So they hired a CDI director, whose No. 1 task,“will be to make sure all the processes are done consistently across all the sites,” McGill says.

Although absence may make the heart grow fonder, lack of communication can quickly turn fondness into indifference.

“You need to get to know your staff so they feel comfortable with you and you feel comfortable with them,” McGill says. But long distances make face-to-face meetings difficult. “It really took me about a year to get to that point because I never really get a chance to see them,” she says.

To keep CDI staff on the same page, McGill holds monthly meetings for all CDI staff with the coding director and two lead coders who also attend. CDI specialists also meet monthly by facility with their immediate directors to discuss productivity, statistics, and facility concerns.

“Communication is definitely one of the big challenges,” says McGill. “You need to be sure you say the same thing individually that you say to the entire group. You have to have open communication and you have to get to know your staff. When concerns come up, they can talk to you one-on-one, pick up the phone and call you, schedule an appointment, or send you an email. Be sure to make time for that. But otherwise I really rely on email.”

Q&A: Sequencing a diagnosis when the phrase ‘versus’ is used

Have a question that is troubling you and your team? Ask us!

Have a question that is troubling you and your team? Ask us!

Q: Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase “versus” between them? For example, the patient arrives with abdominal pain and the physician orders labs and other tests but they all come back normal. In the discharge note, the physician documents “abdominal pain, gastroenteritis versus irritable bowel syndrome (IBS).”

When I first started as a CDI specialist I was told we could not use diagnosis when “versus” was stated, and that we had to query for clarification.

A: Always refer back to the ICD-9-CM (ICD-10-CM/PCS) Official Guidelines for Coding and Reporting if you are unsure of how to sequence or apply codes. Guidelines applicable to your situation are located in Section II, Selection of Principal Diagnosis.

The first guideline states:

“In those rare instances when two or more contrasting or comparative diagnoses are documented as “either/or” (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.”

However, let’s review another guideline from the same section which states:

“When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as secondary diagnoses.”

In the situation described, the physician documented a symptom, abdominal pain, followed by two contrasting diagnoses, gastroenteritis and IBS in the discharge summary. The principal diagnosis is the abdominal pain and secondary diagnoses are the gastroenteritis and the IBS.

If there is no symptom diagnosis documented–for example the physician documents NSTEMI versus GERD–the coder would assign a code for each, sequencing the principal according to the circumstances of the admission (as it tells us to in the Guidelines). Typically, however, the physician will have identified either the presence of the NSTEMI or the GERD, based on enzymes, and other testing.

[more]

ACDIS Advisory Board releases new ICD-10 timeline

Time flies so try to make the most of it.

Time flies so try to make the most of it; check out the latest ICD-10 implementation advice from the ACDIS Advisory Board.

Not sure where you should be in your ICD-10 implementation? The ACDIS Advisory Board created a revised training timeline specifically for CDI professionals. And “stay the course” is its overarching message.

The revised ICD-10-CM/PCS training and implementation timeline which includes quarter-by-quarter and then month-by-month recommendations for preparedness activities. It makes recommendations such as emphasizing PCS coding and record reviews during the fourth quarter of 2014, developing organizational strategies to identify and prioritize documentation risks by January 2015, and incrementally increasing the scope of coders’ and CDI staff members’ dual coding and communication efforts.

Although the ACDIS revised timeline includes many recommended actions, one of the most important elements is fostering facility-wide communication, says Michelle McCormack, RN, BSN, CCDS, CRCR, ACDIS advisory board member and director of CDI for Stanford Hospital & Clinics in Palo Alto, California.

Stanford Hospital & Clinics, for example, has a number of ICD-10 focused working committees that meet regularly, on separate schedules, then come together monthly with organizational leadership to review key activities and accomplishments and jointly tackle barriers to progress.

While dual coding is a big component of the revised ACDIS timeline, if you haven’t begun dual coding, McCormack says that you can make significant  progress by simply revising your electronic templates and query forms for ICD-10.

Editor’s Note: ACDIS members received an exclusive first look at the new timeline via email July 14. Click here to download the timeline and related article.

Medicare Compliance Review provides new blueprint for CDI efforts

Glenn Krauss

Glenn Krauss

If you haven’t seen the OIG report “Medicare Compliance Review of University of Cincinnati Medical Center [UCMC] for Calendar Years 2010 and 2011,” take a look here at the Office of the Inspector General’s (OIG) website.

What you will see is eye-opening: The OIG reviewed a sample of claims that it deemed were improperly billed by the 695-bed hospital, and, by extrapolating the error rate, determined that UCMC owes more than $9.8 million in improper payments.

The next thing you should consider as a CDI specialist is: How can I prevent my hospital from such a similar (potential) catastrophic review by the OIG? By focusing on affecting positive change in clinical documentation that represents “true” documentation improvement vs. a narrowly defined CDI focus on the capture of CCs/MCCs, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, a manager with Accretive Health in Chicago.

CDI specialists tend to look only at solidifying individual diagnoses in the chart, but often ignore equally important supporting information like clinical indicators to support admission to the facility.

“Do we have good solid documentation of the patient’s DRG, or do we have diagnoses with little clinical support? Are we just sending automatic queries?” he asks. “Often we’re not focused on getting a solid, effective, and encompassing history and physical [H&P] that accurately captures the patient’s history of present illness [HPI] reflective of the patient’s severity of illness, signs and symptoms.”

Physicians tend to elaborate on a patient’s past illnesses vs. a patient’s present illness. A sound HPI consists of a chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present, Krauss notes. “There is often inconsistent or lack of clinical context for the reason for the admission. Doctors need this context for their billing, and [hospitals] need it for quality,” he says.

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Book Excerpt: Address AMI changes in ICD-10-CM with alternative queries

CDI Specialist's Guide to ICD-10

CDI Specialist’s Guide to ICD-10

One of the most significant changes within the ICD-10-CM Official Guidelines for Coding and Reporting is the definition of a subsequent myocardial infarction, found in Section I.C.9.e.1, which states:

For encounters occurring while the myocardial infarction is equal to, or less than, four weeks old, including transfers to another acute setting or a postacute setting, and the patient requires continued care for the myocardial infarction, codes from category I21 [ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction] may continue to be reported. For encounters after the four-week time frame and the patient is still receiving care related to the myocardial infarction, the appropriate aftercare code should be assigned, rather than a code from category I21.

This is a change from ICD-9-CM, where the fifth digit of “2” designated an episode of care following the initial episode of care within eight weeks of the MI. In other words, the time frame associated with a new AMI will decrease from eight weeks to four in ICD-10-CM.

Tip: Rather than aggravate providers by explaining to them that as of October 1, 2014, the length of time an MI can be defined as “acute” decreases from eight to four weeks, educate providers to document the age of an MI using the number of weeks (not months) for any MI that occurred within the past three months. Once ICD-10-CM is implemented, if the provider documents a patient had an MI within the past month, a query will be necessary to clarify if it was within the last 28 days, as most months contain 30 or 31 days, which could lead to inaccurate coding. Employing the strategy of documenting the age of the MI in weeks will allow for accurate code assignment in both ICD-9-CM and ICD-10-CM.

The codes within I21 will be associated with an AMI. Codes within the I22, however, are used only when another AMI occurs within four weeks/28 days of the initial AMI. Official Guidelines for Coding and Reporting state:

A code from category I22, Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction is to be used when a patient who has suffered an AMI has a new AMI within the four-week time frame of the initial AMI. A code from category I22 must be used in conjunction with a code from category I21. The sequencing of the I22 and I21 codes depends on the circumstances of the encounter.

The timing change also affects codes in category I23: “Certain current complications following ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction (within the 28 day period).” The tabular list notes state:

A code from category I23 must be used in conjunction with a code from category I21 or category I22. The I23 code should be sequenced first, if it is the reason for encounter, or, it should be sequenced after the I21 or I22 code if the complication of the MI occurs during the encounter for the MI.

Many ICD-10-CM diagnosis codes require documentation of the relationship between conditions. The I23 codes require documentation linking the current condition to the precipitating AMI (that occurred within the prior 28 days). Most of the I23 codes are CCs, but a few are MCCs.

Tip: When communicating with providers, either via query efforts or educational sessions, emphasize the importance of accurately identifying the age of an MI as well as the type, anatomic location, and any consequences of the AMI, as most I23 codes can also be captured when not a complication. Perhaps the most challenging code to accuracy capture within this category will be I23.7: “Postinfaraction angina.”

Editor’s Note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Guide to ICD-10, Second Edition, written by HCPro Boot Camp instructors Jennifer Avery and Cheryl Ericson.

TBT: Salary surveys show industry/profession growth

Here is a "what if" scenario to help illustrate CDI specialists' return on investment.

Take the 2014 CDI Salary Survey.

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you most likely wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We thought we’d pick up on the theme and occasionally go back into our CDI archives to highlight some salient CDI tid-bit rather than our fashion sense (or lack there-of). 

Today, we’ve chosen to take a look at our previous salary surveys and ask you to please participate by taking the 2014 survey. ACDIS members have access to them all in the CDI Journal section of the website. Once you’re on the Journal page simply type “Control F” and add the search word “salary” to locate the articles.

When ACDIS put out the call for participation in its 2014 CDI Salary Survey last week more than 700 people responded. We need you to take a few minutes to complete the survey, too. Why? Because these surveys provide us with a snapshot view of how changes in the profession affect how you get paid for the work you do. And, you can use the results to make the case for changes in your own compensation! It’s true. We’ve heard from a number of ACDIS members who’ve analyzed the data against their own circumstances and got the compensation they deserved. But let’s take a look at what previous salary surveys have illustrated

  • The 2013 CDI Salary Survey garnered more than 700 responses. 25% of respondents said they earned $60,000–$69,999 annually; but the number of individuals earning $50,000-$59,999 decreased by 4% and the number of those earning $70,000-$79,999 increased by about 4%.
  • The 2012 CDI Salary Survey garnered more than 900 responses. 26% earned $60,000–$69,999 annually. Those earning $70,000–$79,999 rose from 16% in 2010 to 20% in 2012.
  • The 2010 CDI Salary Survey (published in January 2011) garnered more than 900 responses. 31% earned $60,000–$69,000 annually. 77% earned between $50,000 and $89,000.
  • The 2009 CDI Salary Survey garnered 330 responses. 32% earned $60,000–$69,999 annually. Only one respondent claimed a salary of less than $30,000, and only one respondent claimed a salary of more than $120,000.
  • The 2008 CDI Salary Survey (the first year the survey was administered) garnered 132 responses. 30% earned $60,000–$69,999 annually.

How have salary rates changes since last year’s survey? You tell us! Please complete the 2014 CDI Specialist’s Salary Benchmarking Survey. We will share the results in a special report later this year.

Q&A: Identifying the MS-DRG for unreleated surgical procedures

Ask your question!

Ask your question!

Q: Could you please explain unrelated surgical procedure DRGs? For example, a patient with a principal diagnosis of pneumonia whose surgical procedure transurethral resection of the prostate (TURP), MS-DRG 168. Also can you explain how we can differentiate between extensive operating room (OR) procedure and non-extensive OR procedure.

A: Many CDI specialists with a clinical background are what I like to call, encoder dependent. What I mean by that is we’ve been trained to “code” using an encoder and create our working MS-DRGs based on “grouper” software. It is often helpful to understand how to manually assign a MS-DRG. The basics steps for assigning a MS-DRG are as follows:

  1. Identify all the applicable diagnoses in the health record
  2. Identify the principal diagnosis (the condition after study to be chiefly responsible for occasioning the admission)
  3. Determine its associated ICD code (we currently use ICD-9-CM, but we’ll eventually use ICD-10-CM)
  4. Identify the base/medical DRG noting its Major Diagnostic Category/body system
  5. Identify any/all procedures

This is where it can get a little tricky. The UHDDS (Uniform Hospital Discharge Data set) defines the principal procedure as

  • One that was performed for definitive treatment, rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication
  • If there appear to be two procedures that are principal, then the one most related to the principal diagnosis should be selected as the principal procedure

If there was a procedure performed take the following steps:

  1. Determine the associated procedure codes (currently based on ICD-9-CM Vol. 3 codes and soon to be ICD-10-PCS) and determine if the procedure code associated with the principal procedure as listed in the DRG Expert?
  2. If the code isn’t in the DRG Expert index of procedures, it is for one of two reasons: Either it is not a “reimbursable” procedure (i.e., one that will affect the MS-DRG assignment) or is it a major OR procedure
  3. If there isn’t a procedure or it doesn’t impact DRG assignment, does the medical DRG allow for movement i.e., can patients be put into different groups based on the presence or absence of a complicating condition (CC) or major complicating condition (MCC)
  4. If so, check to see if any of the remaining diagnoses, which are now considered “secondary diagnoses” are CCs or MCCs
  5. Finalize the working DRG
  6. If the procedure code is in the same MDC/body system as the principal diagnosis assign the new surgical MS-DRG (this is the most common scenario and is often referred to as a “match”)
  7. If the procedure code is not in the same MDC/body system a different process is used to assign the surgical MS-DRG

The MS-DRG system is based on the assumption that if there is a “reimbursable” medical intervention/procedure that the case/claim will remain in the same body system (MDC) as the principal diagnosis will apply. However, there are occasions when the principal procedure is not related to the principal diagnoses because it is associated with a different MDC/body system as in the example you describe, which will require you to take some additional steps, including:

  1. Turn to the start of “DRGs Associated with All MDCs.”
  2. Scan the procedure codes listed under DRG 984 Prostatic O.R. Procedure Unrelated to PDX to try to locate the applicable procedure code.  These are codes that range from 60.0 to 60.99 within ICD-9-CM Vol. 3. If the applicable code is found under DRG 984 then the case will fall within a DRG referred to as a “triplet” where either a CC or a MCC can “move” the DRG. Check the remaining diagnoses codes to see if any are classified as a CC or MCC and finalize the working DRG based on the value of the applicable secondary diagnoses resulting in a final DRG between 986 and 984

Your example of a principal diagnosis of pneumonia (respiratory system MDC) with a procedure of a TURP will fall into one of these DRGs because the TURP is not a procedure located within the respiratory MDC/body system, but is classified as a prostate procedure and found under DRG 984. Your final MS-DRG assignment will depend on the presence or absence of secondary diagnose classified as a CC or MCC.

If the procedure code is not found under DRG 984, scan the procedure codes listed under DRG 987 Nonextensive O.R. Procedure Unrelated to PDX to try to locate the applicable procedure code. These codes span several pages within the DRG Expert. If the applicable code is found under DRG 987 then the case will fall within a DRG referred to as a “triplet” where either a CC or a MCC can “move” the DRG. Check the remaining diagnoses codes to see if any are classified as a CC or MCC and finalize the working DRG based on the value of the applicable secondary diagnoses resulting in a final DRG between 987 and 989.

If the procedure code is not found under DRG 984 or DRG 987 and it was not associated with a page when referencing a procedure index or if it was found, it was in a different MDC/body system than the PDX then the assumption is the case/claim belongs in DRGs 981-983. This final step requires a leap of faith since it is based on a process of elimination where this is the “last resort” for DRG assignment. These DRGs are heavily scrutinized by external auditors as assignment within these DRGs can erroneously inflate reimbursement if the case was improperly assigned. As above, this is a DRG is a “triplet” where either a CC or a MCC can “move” the DRG. So check the remaining diagnoses codes to see if any are classified as a CC or MCC and finalize the working DRG based on the value of the applicable secondary diagnoses.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.