Medicare SeverityDiagnosis Related Groups MSDRGs

1
Medicare Severity-Diagnosis Related Groups
(MS-DRGs)

• Presented by
• Lenore M. Whalen, RHIT, CCS, CCS-P
• August 2007

2
Agenda

• History of Current DRGs
• MS-DRGs?
• Refinement of DRGs Based on Severity of Illness
• CC List
• Use of Acute Diagnosis Codes

3
History of Current DRGs

• Current system in effect since FY1983
• Based on PDX
• 8 additional codes CCs
• 6 procedures
• Also based on
• Age
• Sex
• Discharge status

4
H/O Current DRGs (continued)

• MDCs clinically coherent
• Single organ system
• 538 DRGs/25 MDCs
• Pre-MDC
• Based on high resource consumption
• 9 current Pre-MDCs

5
H/O Current DRGs (continued)

• Divided into medical and surgical DRGs
• Surgical DRGs based on hierarchy
• Based on resource intensity
• Some non-OR procedures drive certain DRGs
• Medical DRGs based on diagnosis age (0-17 years
  of age or greater than 17 yrs of age)

6
Fiscal Year 2008

• Can in DRG methodology
• MS-DRGs
• Recognized severity of illness and resource use
• Based on complexity
• RAND corp. used to review different methodologies
• 5 different ones compared

7
MS-DRGs

• Result of CMS-DRGs to account for severity
• Will continue to be evaluated by RAND
• Assumed no behavioral changes in coding practice
  or types of patients treated
• Teaching hospitals commonly treat higher number
  of complex cases

8
Coding Pattern Change?

• Increases in CMI could be result of improved
  coding not increases in patient severity
• Past 24 yrs have resulted in improved coding and
  documentation
• Will still require more appropriate documentation
  to attain appropriate MS-DRG assignment

9
MS-DRGs

• Comprehensive approach in applying severity of
  illness
• Improve ability to identify groups of patients
  with varying levels of severity using secondary
  diagnoses

10
Objective in Creation

• Homogeneous subgroups significantly different in
  resource use
• Have enough volume to be meaningful
• Improve ability to explain variances in resource
  use

11
CC List

• Current system
• 115 DRGs split based on presence/absence of CC
• Assigns to higher weighted DRG
• CC any secondary diagnosis that.would cause an
  increase in length of stay by at least 1 day in
  75 of patients

12
CCs/Secondary Diagnosis

• Dramatic changes in coding of secondary diagnosis
• Change in characteristics of patients admitted to
  hospitals and practice patterns
• Medicare average LOS dropped dramatically from
  9.3 days to 5.7 days
• Increased availability of postacute care services
• NH, HHS, day surgeries, etc.

13
CCs/Secondary Diagnosis (continued)

• Patients admitted today more likely to have CC
• 80 patients today
• CC list has not been reviewed in 22 years to
  determine whether they are appropriate

14
Secondary Diagnosis

• May require increased hospital resources because
  of such services as
• Intensive monitoring
• Expensive and technically complex services, e.g.
  heart transplants
• Extensive care requiring greater number of
  caregivers, e.g. increased nursing care for a
  quadraplegic

15
CCs/MCCs

• 3,326 diagnosis on current list
• MS-DRGs will decrease number to 2,583
• 77.6 of patients have at least one CC
• Revised list
• Reduced to 41.24

16
Coding Guidelines

• Have not changed!
• Cannot report symptom/signs when they are
  inherent in disease process
• Remember Basic Coding Guidelines still in effect
• Remember UHDDS Guidelines still prevail.
• Principal Diagnosis is that condition after study
  that occasioned the admission of the patient to
  the hospital.

17
Chronic Diagnosis Codes

• Usually do not cause significant increase in
  hospital resource use
• Unless presence of acute exacerbation, or
• Deterioration in underlying chronic condition
• Number of I-9 codes include acute exacerbation of
  underlying condition

18
Acute Exacerbation of Chronic Condition

• Example Congestive Heart Failure following codes
  specify acute exacerbation
• 428.21 Acute systolic heart failure
• 428.41 Acute systolic and diastolic HF
• 428.43 Acute on Chronic systolic HF
• 428.31 Acute diastolic HF
• 428.33 Acute on chronic diastolic HF

19
CHF Codes not Acute Exacerbation

• 428.0 CHF not otherwise specified
• 428.1 Left heart failure
• 428.20 Systolic HF NOS
• 428.22 Chronic systolic HF
• 428.32 Chronic diastolic HF
• 428.40 Systolic and Diastolic HF
• 428.9 Heart Failure NOS

20
New MS-DRGs

• Recognize increase resource use secondary to
  severity of illness
• Used current CC list to affect changes under
  MS-DRGs
• 3 sub-divisions of MS-DRGs
• DRG w/MCC
• DRG w/CC
• Non-CC DRGs

21
Three levels of MS-DRGs

• MCCs reflect highest level of severity
• CCs reflect next level of severity
• Non-CCs do not significantly affect severity of
  resources or resource use
• Will not affect DRG assignment
• Will result in lowest DRG within group

22
Five Criteria to Meet CC/MCC

• Reduction in variance of charges of at least 3
• At least 5 of patients falling within CC/MCC
  subgroup
• At least 500 cases
• At least 20 difference in average charges
  between subgroups
• 4,000 difference in average charge

23
DRGs vs MS-DRGs

• PDX 482.41
• 2ºDX 427.31
• 428.0
• DRG 079
• Resp. Infection w/CC
• R.W. 1.6262
• LOS 8.3

• PDX 482.41
• 2ºDX 427.31
• 428.31
• DRG 177
• Resp.Infection w/MCC
• R.W. 2.0432
• LOS 9.5

24
DRGs vs MS-DRGs

• PDX 482.41
• 2ºDX 427.31
• 428.31
• DRG 177
• Resp.infection w/MCC
• R.W. 2.0432
• LOS 9.5

• PDX 482.41
• 2ºDX 491.21
• 599.0
• DRG 178
• Resp.infection w/CC
• R.W. 1.4992
• LOS 7.7

25
DRGs vs MS-DRGs

• PDX 482.41
• 2ºDX 491.21
• 599.0
• DRG 178
• Resp.infection w/CC
• R.W. 1.4992
• LOS 7.7

• PDX 482.41
• 2ºDX 427.31
• 496
• DRG 179
• RI w/No MCC/CC
• R.W. 1.0448
• LOS 5.8

26
DRGs vs MS-DRGs

• PDX 428.31
• 2ºDX 427.31
• 486
• DRG 127
• Heart Failure Shock
• R.W. 1.0485
• LOS 5.1

• PDX 428.31
• 2ºDX 427.31
• 486
• DRG 291
• Heart Failure Shock w/MCC
• R.W. 1.4760
• LOS 6.8

27
DRGs vs MS-DRGs

• PDX 428.31
• 2ºDX 427.31
• 486
• DRG 291
• Heart Failure Shock w/MCC
• R.W. 1.4760
• LOS 6.8

• PDX 428.31
• 2ºDX 427.31
• 491.21
• DRG 290
• Heart Failure Shock w/CC
• R.W. 1.0169
• LOS 5.2

28
Structure of MS-DRGs

• 311 Base MS-DRGs
• 335 base DRGs minus MDC 14 5 and error DRGs
• Subdivided into 3 CC subgroups
• MCC subgroup have charges double average charge
  for CCgroup
• 41.1 in subfroup with non-CC

29
Structure (continued)

• Documentation key to assigning appropriate
  diagnoses codes
• Secondary diagnosis key to assigning appropriate
  MS-DRG
• E Codes not assigned to MCC/CC
• Congenital anomalies not MCC/CC

30
Structure (continued)

• Codes associated with mortality assigned
  different CC subclasses
• Depended on whether patient lived or died
• These codes are
• 427.41 Ventricular fibrillation
• 427.5 Cardiac arrest
• 785.51 Cardiogenic shock
• 785.59 Other shock w/o mention of trauma
• 799.1 Respiratory arrest
• Assigned MCC if patient lives, non-CC if patient
  dies

31
MS-DRGs Assignment

• 13 intestinal transplant DRGs are assigned to
  MS-DRG 005
• Based on
• Secondary DX
• Charges and average LOS
• Retitled
• MS-DRG 005 Liver Transplant with MCC or
  Intestinal Transplant

32
MS-DRGs Assignment (continued)

• CMS-DRGS 12 Craniotomy agegt17 w/wo CC
• MS-DRGs 37, 38 39 Extracranial Procedures with
  MCC, w/CC, w/o MCC/CC
• CMS-DRG 543 Craniotomy w/Major Device Implant or
  Acute Complex CNS PDX
• MS-DRGS 23 24 Craniotomy w/Major Device
  Implant or Acute Complex CNS PDX w/wo MCC/CC

33
MS-DRG Assignment (continued)

• Codes 39.72, 39.74, and 39.79 to MS-DRGs 011 thru
  013 and 543
• Code 00.62 is assigned to MS-DRGs 37, 38, 39, 23
  and 24 divided by presence/absence of specific
  CCs
• Code 00.65 Percutaneous Insertion of Intracranial
  Vascular Stent(s) must be reported with 00.62 in
  order for correct assignment to above MS-DRGs
• If not present, Code 00.62 will fall under
  Non-Covered Procedure services.
• Will fail the MCE edit

34
Hip and Knee MS-DRGs

• Revision CMS-DRGs 544 and 545 MS-DRGs 466, 467,
  468, 483 and 484
• Based on severity of illness and resource costs

35
Myeloproliferative Diseases and Disorders

• Endoscopic Procedures under CMS DRG 412 History
  of Malignancy w/Endoscopy MS-DRGs 843, 844 and
  845
• Codes 33.71, 33.78, and 33.79 all endoscopic
  codes related to bronchial valve replacement,
  bronchial device removals, and bronchial
  insertion of device or substances, respectively

36
CMS-DRGs 468, 476 and 477

• 468 Extensive OR procedure unrelated to PDX will
  be divided into 3 MS-DRGs (981,982, 983) based on
  presence / absence of MCC/CC
• 476 Prostatic OR Procedure Unrelated to PDX will
  be divided into 3 MS-DRGs (984, 985, 986) based
  on presence / absence of MCC/CC
• 477 Nonextensive OR Procedure Unrelated to PDS
  into 3 MS-DRGs (987,988,989) based on
  presence/absence of MCC/CC

37
Conclusion

• MS-DRGs will provide more severity adjusted DRG
  PPS methodology
• MS-DRGs will reflect resource consumption
• MS-DRGs reordered and renamed all DRGs
• MS-DRGs will be divided into 3 DRGs within base
  DRGs
• Those with MCC
• Those with CC
• Those with no MCC/CC

38
Conclusion (continued)

• Chronic conditions most likely will not be CCs
  unless they become acute exacerbations
• Pre-MDCs now part of MS-DRGs
• Listed in MDC 1
• MS-DRGs increased to 745 from 335
• Documentation and secondary diagnosis more
  important then ever.