RSSAll Entries Tagged With: "DRG"

Note from the Instructor: Your 2018 IPPS Final Rule questions, answered

Allen Frady

Allen Frady, RN-BSN, CCDS, CCS, CRC

By Allen Frady, RN-BSN, CCDS, CCS, CRC

Yesterday, 845+ codes took effect thanks to the fiscal year 2018 IPPS Final Rule, which was released at the beginning of August. As you review the updates, additions, and deletions in this year’s rule, I wanted to answer some of your burning questions to help guide you through this transition.

1.) Is it true that chronic obstructive pulmonary disease (COPD) does not have to be sequenced before pneumonia?

The Index for 2017 had the language “use additional code to identify infection.” This was misinterpreted as applying to conditions such as pneumonia by both coders using the index and the AHA’s Coding Clinic. “Use additional code” means that a subsequent diagnosis must be sequenced as a secondary code. However, “use additional code to identify infection,” usually means to assign an additional organism code from the organism code category of B95 to B97. [more]

Use a DRG Expert? Me? Um, no thanks.

If you don't already, start learning how to use the DRG Expert today!

If you don’t already, start learning how to use the DRG Expert today!

“Why do I need to know how to use a DRG Expert to take the CCDS exam? I don’t have to use that book to do my job.”

I hear this a lot. The reason you don’t use a DRG Expert is probably because you use an encoder. Since you can’t take an encoder into the exam room, you’re going to have to rely on the book.

Even if you don’t plan to (or need) to take the CCDS exam, you should still learn how to use the book. It can be a valuable tool for CDI specialists, and is often overlooked in the CDI community. You may find yourself without access to the electronic supports that calculate DRGs for you. Your system crashes. You seek new employment or pickup additional hours in a facility that requires manual research. You have to demonstrate your expertise or defend an assigned DRG. The list of reasons goes on and on.

The June 25 issue of CDI Strategies has an excellent article authored by ACDIS CDI Education Director Cheryl Ericson [more]

Q&A: Unrelated surgical procedure DRGs

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: Could you please explain unrelated surgical procedure DRGs? 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 “encoder dependent,” trained to “code” using an encoder and taught to create a working MS-DRG based on “grouper” software. However, CDI specialists should understand how to manually assign a MS-DRG, too. The basics steps for assigning a MS-DRG are.

  1. Identify all the reportable diagnoses in the health record and assign their applicable ICD code (we currently use ICD-9-CM, but will transition to ICD-10-CM)
  2. Identify the principal diagnosis (the condition “after study” determined to be chiefly responsible for occasioning the admission), the remaining diagnoses are secondary diagnoses some of which may be classified by CMS as a complicating or comorbidity (CC) or major complication or comorbidity (MCC)
  3. Use the alphabetic index of diagnoses in the DRG Expert to identify the base/medical MS-DRG noting its Major Diagnostic Category (MDC)/body system (the MDC is necessary to assign the surgical MS-DRG when applicable) by scanning the MS-DRGs associated with the listed pages to see which applies to the particular scenario
  4. Identify any/all reportable procedures and their associated procedure code (ICD-9-CM Vol. 3 until we transition to ICD-10-PCS)


TBT: Baseline DRG and CMI as metrics for success

Take a closer look at hypotension documentation

While the baseline DRG may seem like a simple concept, it can at times be difficult to determine.

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. We’ve picked up the theme going back into our archives to highlight some salient tid-bit. Today, we’re looking at a piece from the October 2011 CDI Journal, “Use baseline DRG, CMI as metrics for success, with caution,” written by Jonathan Elion, MD, FACC.

While the baseline DRG may seem like a simple concept, it can at times be difficult to determine. Consider the following clinical case:

A patient is admitted through the emergency department (ED) after presenting with undiagnosed abdominal pain. While not optimal, this single symptom has a corresponding ICD-9 code (789.00), which would result in DRG 392, with a reimbursement at a representative hospital of $5,008.

Further testing, however, reveals that the abdominal pain is the result of acute cholecystitis (ICD-9 575.10); this would result in DRG 446 (disorders of the biliary tract without complication), which is reimbursed $5,175.

The CDI specialist notes an increased creatinine and a decreased glomerular filtration rate and queries the physician regarding the patient’s renal status. If the doctor provides proper documentation, it could be possible to assign a complication for Stage IV chronic kidney disease (ICD-9 585.4), which would result in DRG 445 (disorders of the biliary tract with CC), reimbursed a total of $7,464

The patient undergoes a laparoscopic cholecystectomy (ICD-9 51.23), changing the DRG to 418 (laparoscopic cholecystectomy with CC), with a resulting reimbursement of $11,868.

Next, the patient develops shortness of breath, and the consulting cardiologist documents acute-on-chronic congestive heart failure (ICD-9 428.23), changing the DRG to 417 (laparoscopic cholecystectomy with MCC) with a resulting reimbursement of $17,478.

So what is the baseline DRG, and what impact did the CDI specialist have on this case? In my opinion, it is not fair to conclude that the value of the query was $12,470, the difference between the first scenario shown above and the last. At my hospital, the “admitting diagnosis” is entered by an admissions clerk. This does not qualify as proper data on which to base any calculation of the CDI team’s importance. Regrettably, however, sometimes the admitting diagnosis is used as the baseline.

Furthermore, you have to consider that the surgeon did not take the patient to the operating room based on the CDI specialist’s query about the patient’s renal status. Additionally, the MCC that ultimately drove the reimbursement level was provided independently by the cardiology consultant, with no prompting from the CDI staff.

Would it surprise the CDI director, then, to learn that the true financial impact of the CDI specialist in this instance was $0? The documentation of the chronic kidney disease is, of course, important to the completeness and accuracy of the record on this patient, and SOI or ROM may be affected. But claiming any direct financial benefit from the CDI specialist’s involvement with this patient’s documentation is not warranted.

Last Week on CDI Talk: Opportunities in the pediatric setting

Editor’s Note: CDI Talk is a networking forum for ACDIS members, in which members ask pressing questions and garner the opinion and expertise of their peers. Pediatric CDI Talk is a forum specifically designed for CDI specialists in pediatrics. Join by clicking on the CDI Talk tab on the ACDIS website.

Pediatrics, though still relatively new in the CDI profession, has generated a lot of discussion in CDI programs. With more and more CDI specialists making their way in to pediatric settings, questions about different processes and documentation often arise.

Broaden the scope of your CDI efforts by looking for medical necessity indicators and increasing proactive efforts to protect the record against audit risks.

There are plenty of opportunities for new pediatric CDI programs to make a difference.

In one recent discussion on Pediatric CDI Talk, users brainstormed what they consider to be the top 10 DRGs and the biggest opportunities within the pediatric population, specifically for newer pediatric CDI programs. Here’s a preview of the discussion:

The top DRGs in pediatrics often vary, according to Karen Bridgeman MSN, RN, CCDS, CDI educator, and Clinical Documentation Integrity at the Medical University of South Carolina in Charleston. Asthma and seizures are the high-volume DRGs at her facility and respiratory failure is the opportunity with the most impact, adding that pediatric physicians may prefer the term “respiratory distress,” Bridgeman says.

Education, she says, has been a key factor in helping physicians understand the proper terms for more accurate documentation. For example, with seizures, the biggest impact is with the term ‘intractable’ or ‘medically refractory,’ says Bridgeman, who will be presenting a more in-depth look on pediatric CDI at this year’s annual conference.

While these terms are not CCs or MCCs, they affect the patient’s severity of illness. CDI specialists may need to query for intractable or medically refractory in patients suffering breakthrough seizures, increase in frequency not due to medical noncompliance, and patients on ketogenic diets.

Overall, hospitals should determine what the most common DRGs are and go from there, Bridgeman says.

“If you are new in reviewing pediatrics, I would start slowly, giving yourself and staff time to learn nuances in pediatric coding and to learning about the pediatric population,” she says. “I would not start with the neonates, as those are tricky and have their own code set.”

Very sick children may respond quickly to therapeutic interventions and, thus, pediatricians may often be reluctant to use terms that are frightening to anxious parents, says Larry Faust, MD, FAAP, a physician at CDIMD in Clarksville, Tennessee. Physicians receive reimbursement for their services based on their submitted CPT codes, not ICD-9-CM (ICD-10-CM/PCS) or MS-DRGs, so most pediatricians have not been educated on DRGs or the impact of diagnostic specificity. Pediatricians may use clinical language that is quite clear to colleagues, but is not congruent with codeable terms.

Prominent documentation opportunities, Faust says, include respiratory failure, asthma versus bronchiolitis, sepsis, shock, acute kidney injury, malnutrition, specificity of seizures, etiology of altered mental status, and complex pneumonia with failure to document suspected etiologies.

Establish policies regarding DRG discrepancies

The Physician Queries Handbook.

What do you do when a CDI specialist arrives at one MS-DRG and the coder arrives at another? The answer is far from simple and depends on the circumstances at your particular facility, says ACDIS Director Brian Murphy.

“Most often the coder, due to his/her experience and training in coding guidelines and access to coding resources such as an encoder or other programs, is responsible for final DRG assignment,” Murphy says.

Many organizations support the coders’ right to make the final decision, says Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., in Danvers, Mass. In fact, coders may even be held liable for coding inappropriately should such errors be discovered as a pattern established to gain unearned compensation for a facility.

In a 2005 Federal Register notice the Office of the Inspector General (OIG) set forth its “Supplemental Compliance Program for Hospitals.” Although the document contains information primarily pertinent to hospital compliance officers, CDI specialists should review it to gain perspective on the variety of coding and billing missteps being targeted by government agencies, Ericson says.

Typically, CDI specialists come from the nursing world. (For evidence see the July 2012 CDI Salary Survey, which states that 72% are RNs.) They look for clinical indicators of diagnoses not currently in the medical record. Conversely, coders must look in the medical record for existing documentation and assign a code based solely on that documentation. The query process, employed by both CDI and coding staff, aims to ask questions of the physicians when the documentation is unclear, ambiguous, conflicting, poorly written, or just plain confusing.

In the past year, we have heard some discussion about the viability of concurrent coding by CDI specialists. Opinions differ about the effectiveness of this model. In the January 2013 edition of the CDI Journal, sources discuss their experiences with concurrent coding efforts. They suggest success depends on the development of clear policies and processes, effective hiring of competent, experienced professionals (including coders) to the team, and appropriate access to electronic tools and systems such as the aforementioned encoders and electronic query systems.

To prioritize their efforts CDI specialists learn the process of how to examine the record and assign what’s known as a “working DRG”—an MS-DRG that may change during the course of the patient’s stay as diagnoses are determined and care provided. Determining how the CDI team’s efforts meet and mesh with those of their coding counterparts should be part of a joint (perhaps even steering committee-level) decision at the time of CDI program implementation.

The Physician Query Handbook, Chapter 3, “Query Process Infrastructure,” includes a section on what to do with DRG mismatches. It states:

“…[cases where] the CDI specialists’ final DRG does not match the final coded DRG, [DRG mismatches] may occur for a variety of reasons… Regardless of the reason the reconciliation of these DRG mismatches represents a great learning opportunity for all involved if proactively addressed. A robust conversation of the discrepancies can lead a CDI specialist to a deeper understanding of the coding rules and regulations and [may] help coders better understand the clinical thinking of the CDI [nursing] staff. Used as a learning tool, discussion of DRG mismatches also represents a good way to foster mutual respect and understanding of the various teams’ knowledge base and job responsibilities.” (p. 59.)

The section goes on to advocate that CDI programs establish policies and procedures for how to handle DRG reconciliation as part of the CDI program creation (view a sample policy in the Forms & Tools Library). These policies may simply require the coder and CDI specialist review the record together to discuss the discrepancy, they may give the final word to the coder, or they may indicate that cases where DRG mismatches occur should be passed on to the coding manager or physician advisor for final review and input. Regardless of how your CDI program decides to handle the concern, addressing the matter upfront and putting it in a clear policy may help to resolve future interdepartmental conflicts.

Coding for inpatient postoperative complications requires explicit documentation

Capture appropriate documentation for coding postoperative complications.

Determining when to code a post-surgical complication as opposed to simply considering it to be an expected outcome after surgery can be a complicated task.

A complication is “a condition that occurred after admission that, because of its presence with a specific principal diagnosis, would cause an increase in the length of stay by at least one day in at least 75% of the patients,” according to CMS.

Therefore documentation of a postoperative condition does not necessarily indicate that there is a link between the condition and the surgery, according to Audrey G. Howard, RHIA, senior consultant for 3M Health Information Systems in Atlanta, who will join Cheryl Manchenton, RN, BSN, an inpatient consultant for 3M Health Information System on Thursday, July 12, for a live audio conference “Inpatient Postoperative Complications: Resolve your facility’s documentation and coding concerns.”

For a condition to be considered a postoperative complication all of the following must be true:

  • It must be more than a routinely expected condition or occurrence, and there should be evidence that the provider was evaluating, monitoring, or treating the condition
  • There must be a cause and effect relationship between the care provided and the condition
  • Physician documentation must indicate that the condition is a complication

According to Coding Clinic, Third Quarter, 2009, p.5, “If the physician does not explicitly document whether the condition is a complication of the procedure, then the physician should be queried for clarification.”

Coding Clinic, First Quarter, 2011, pp. 13–14 further emphasizes this point and clarifies that it is the physician’s responsibility to distinguish a condition as a complication, stating that “only a physician can diagnose a condition, and the physician must explicitly document whether the condition is a complication.”

For example, a physician may document a “postoperative ileus,” but it is very common for a patient to have an ileus after surgery, Howard says. Therefore, this alone does not qualify as a postoperative complication.

“If nothing is being evaluated, monitored, [or] treated, increasing nursing care, or increasing the patient’s length of stay, I would not pick up that postop ileus as a secondary diagnosis even though it was documented by the physician,” Howard says.

Editor’s Note: This article first published on

To register for the July 12 program visit

Incorporate awareness of transfer DRGs into CDI record review efforts

CMS never met a dollar it didn't want back.

CMS never met a dollar it didn’t try to recoup. So we have RACs and HACs and stacks of regulatory requirements that take many, many healthcare dollars to manage. The post-acute care transfer DRGs are but one example.

(RACs, of course, are Recovery Audit Contractors which the government recently renamed Recovery Auditors or the Recovery Audit Program. And I’m sure you all know that HACs stands for hospital acquired conditions.)

For the uninitiated, post-acute care transfer DRGs exist because CMS doesn’t want to pay the hospital the full freight if the patient receives follow-up care somewhere else, and it ends up having to pay the another facility or healthcare agency (such as home health) as well. When the program began, 10 DRGs were designated as transfer DRGs; that list has since expanded to 273.

You can download the current list here.

Why do you need to know about transfer DRGs?

The CDI specialist is one of the few people who has at least a general idea of where the DRG is going to land before the patient is discharged. As you know, every DRG is attached to both an arithmetic length of stay (A/LOS) and a geometric length of stay (G/LOS). The A/LOS is the average LOS of patients within that DRG, including transfers and long-stay outliers. The G/LOS is the national mean length of stay for that DRG, except for transfers and long-stay outliers. The A/LOS is used for calculating outlier payments, while the G/LOS determines the transfer DRG payments. If you don’t have a good idea of the DRG before you transfer the patient or discharge the patient with services, your facility’s number crunchers could have an unpleasant jolt at reimbursement time.

When a patient is transferred to another facility or home with services after staying fewer days than the transfer DRG’s G/LOS, the post-acute care transfer DRG rule kicks in. Instead of receiving the full DRG reimbursement (relative weight multiplied by the hospital’s blended rate), a per-diem rate applies. The per-diem rate is the DRG reimbursement divided by the G/LOS. The hospital will receive twice the per-diem rate on day one and the per-diem rate every day thereafter up to the full DRG reimbursement.


Q&A: How to resolve DRG confusion

Q: Confession. I am very frustrated. I am fairly new to CDI. I have a nursing background. I’m trying to understand how

Learning how to navigate the coding and DRG landscape can be daunting. Don't worry. Others have had to learn this too. Ask for help and know you are in good company.

the coding and DRG system works. But when I look up a diagnosis in the DRG Expert in the alphabetic index to diseases it is not listed as I would expect it to be.

Take for example, bradycardia. It is not listed under that term or arrhythmia.  Yet, it is listed under cardiac arrhythmia. For another example, how about anorexia? The only listing is anorexia nervosa—not unspecified.

I also find it ironic that I cannot infer what a physician is stating (it has to be documented precisely) but when I have to look up a term I have to guess its meaning.

Do you have any advice for me?

A: Your frustration is very common among new clinical documentation improvement (CDI) specialists.  The publishers of the DRG Expert did not include the same type of Index to Diseases that you would find in Volume I of an ICD-9 code book—probably to save space. The Index to Diseases alone in my code book is 380+ pages.

This is one reason that during the CDI BootCamp I mention so many diagnoses as we review Medicare Severity Diagnosis-related groups (MS-DRGs) in a major diagnostic category (MDC) and either have you highlight them or write them in, because I, too, had exactly the same issues you are having.

Every CDI team should also have a coding book in their department to use as a reference (ask your facility HIM department if they have an old one you can have), especially if you do not have access to the encoder (coding and reimbursement software), which would let you look up whatever you wanted—however, even that has limitations, because search terms often use “coding language” rather than the everyday language of clinicians.

As far as your comment regarding the irony of the situation, all I can say is “Right on, girl!”  It is the reason we have taken on this role. We were hired to become the “translators” or “interpreters” to ensure that the clinical language matches the language needed by the coders. Acquiring the skills to understand both of these languages, along with the ability to translate from one to the other, is what makes us, as CDI professionals, unique.

As a final note, I just want to share that my very first DRG Expert was COVERED from end to end with handwritten notes, stickies, and slips of paper. I used this book for three years, copying my info into each new edition until I was granted encoder access. Every time I asked a coder where to find something I wrote it in the book—especially those diagnoses that had really strange “code” descriptions.

I hope that I can assure you, that by this time next year, you will have many of these coding terms memorized.

I tell all my CDI BootCamp students that there is a long learning curve to this position, so don’t worry. While some people catch on quickly, for most it may take up to six months before that proverbial light bulb finally goes on and frequently it takes up to a year to feel confident in the role.

Don’t get discouraged. Most CDI specialists will tell you the same thing! Before you know it, you will find yourself sitting in traffic, converting license plate numbers into DRGs or diagnosis codes.

Q&A: Maryland CDI network answers member’s renal failure documentation inquiry

Q: If the physician documents throughout the record that the patient has acute renal failure (ARF)—he documents this in emergency department notes, history and physical, admitting diagnosis, and in the progress notes but fails to add it to the discharge summary—would the coder be allowed to pick up the acute renal failure and code for it or would the coder leave it out and until the CDI specialist queries the physician for documentation in the discharge note?

Additionally, if the physician documents ARF in the initial consult note while the patient was still in the emergency department and it is documented in the chart by the attending physician and the renal consult but the hospitalist who last saw the patient documents renal insufficiency in discharge summary, would you leave out the ARF completely just code the renal insufficiency or would you query the hospitalist?

A: “Oftentimes, diagnoses throughout the patient’s stay are left out of the discharge summary and yet are still coded, if there is documentation in the record to support those diagnoses.” states Lillian Keane, RN, BSN, CPC, documentation specialist at MedStar Health Good Samaritan Hospital.

Keane suggests also reviewing the labs (creatinine, glomerular filtration rate [GFR]) and using the RIFLE (risk, injury, failure, loss, end-stage kidney disease [ESKD]) classification published by the Acute Dialysis Quality Initiative (ADQI) group to assist in diagnosis of ARF.

In regard to the second scenario, Keane favors querying the physician for clarification since so many physicians use the term acute renal insufficiency and ARF as one and the same. “If the diagnosis of ARF is inconsistent with the RIFLE and there is conflicting documentation, I will query at that point,” says Keane.

“We also see the terms acute renal failure and acute renal injury used interchangeably at our facility,” says Cathy DeNoble, BS, RHIA, CCS, LPN, coordinator of Case Mix Information Management and CDI specialist at Johns Hopkins Health System in Baltimore. “They are easily misinterpreted acronyms with various definitions.  At our facility the attending is the final word and when in doubt…query never assume.”

Understanding the difference between the physician’s mindset and the coding rules, presents an educational opportunity, says Keane, who presented physician education sessions on RIFLE classification, differentiating acute renal insufficiency versus ARF versus azotemia and also the stages of chronic kidney disease.

Keane cites the September 2010 article of the month AKI: The Crossroads of ICD-9-CM and Medical Literature by James S. Kennedy, MD, as one resource, other resources on the ACDIS website include:

Editor’s Note: Special thanks to The Maryland Hospital Association Clinical Documentation Improvement Workgroup for sharing this exchange. For information about joining Maryland’s networking events contact Christine Mobley, RN, director of clinical documentation at Prince George’s Hospital Center, at