Most Responsible Diagnosis

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Most Responsible Diagnosis Complexity Coding

• HS317B Coding Classification of Health Data

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Background on Standards

• In 1995 at a First Ministers meeting, the
  federal, provincial territorial governments
  agreed that Canada would adopt a unified system
  for the collection of health care data.
• Discharge Abstract Database (DAD
• National Ambulatory Care Reporting System (NACRS)
• In 2001 ICD-10 was introduced to Canada in a
  staggered approach.
• Canadian Coding Standards for ICD-10-CA enhance
  the World Health Organizations rules
  guidelines.

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The idea to create a database of health
information that is relevant
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Health Information Database

• At a local level to demonstrate
• quality improvement, program planning,
  benchmarking, research, strategic planning,
  utilization management, risk management, case
  costing funding
• Provincially
• case costing, funding, rationalization of
  services, population health, system evaluation
  planning
• Nationally
• evaluation of outcomes, grouping of data,
  healthcare planning, manpower planning,
  monitoring trends, morbidity and mortality
  reporting, patient safety

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• Most Responsible Diagnosis
• Diagnosis Typing
• Interventions
• Data Elements (demographics, etc)

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Process for Classification

• Identify Most Responsible Diagnosis
• Based on MRDx coded cases are slotted into one of
  25 major clinical categories (MCC).
• Cases are grouped to similar conditions together
  into Case Mix Groups

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Medical/Surgical CMG Methodology
No
Valid MRDx?
CMG 999
Yes
Yes
Age lt 29
MCC 15
Days
No
Yes
Yes
Yes
Assign MCC Based
O.R.
on Most responsible
Surgical Partition
Procedure In MCC
Procedure
Diagnosis
No
No
Unrelated O.R.
Medical Partition
Procedure
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MCC into Case Mix Groups

• Grouping similar types of patients and or
  resources together into CMGs

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Most Responsible Diagnosis

• It is the one diagnosis or condition that can be
  described as being most responsible for the
  patients stay in hospital
• If there is more than one such condition, the one
  held most responsible for the greatest portion of
  the LOS or greatest use of resources should be
  selected
• If no diagnosis was made, the main symptom,
  abnormal finding or problem should be selected as
  MRDx

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• Patient was playing hockey at an arena when he
  was struck by another players stick, falling on
  his right arm. He sustained a 5 cm laceration on
  his head. He also experienced pain in his right
  arm. In hospital he had a CT scan of his head
  which was normal. X-ray of his right arm
  revealed a fracture of the ulnar shaft.
• He was taken to the OR for fixation of the radius
  with a plate. The laceration was also sutured.

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Which condition would be the MRDx?

• Laceration of the scalp
• Fracture of the radius
• Why?

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• Patient presents to hospital with acute chest
  pain. After being admitted to hospital for
  observation and diagnostic testing (heart
  catheterization and ECG) no definite cause could
  be found. The chest pain gradually resolved and
  the patient was discharged.

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What is the MRDx?

• If no definite diagnosis is made, the main
  symptom, abnormal finding or problem should be
  selected as MRDx.

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Choosing between two or more diagnosis of equal
importance

• Acute Gastritis
• Acute Duodenitis
• Acute Bronchitis

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Diagnosis of equal importance

• When two or more diagnosis of equal importance
  are listed
• No clear indication as to which one is MRDx
• Select the condition for which a definitive (as
  opposed to diagnostic) surgical or non-surgical
  procedure has been performed
• If no surgery performed select the first-listed
  diagnosis as the MRDx

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Specificity

• Peptic Ulcer Disease
• Chronic Bleeding Duodenal Ulcer
• Cerebrovascular Accident
• Cerebral hemorrhage

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Specificity

• When the main diagnosis describes a condition
  in general terms
• Select a more precise code about site or nature
  if there are more descriptive terms reported
  among the other diagnosis

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Using Diagnostic Test Results

• Patient was admitted for skin lesion. Pathology
  report showed squamous cell carcinoma

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Using Diagnostic Test Results

• Use
• Laboratory,
• X-ray,
• Pathology,
• Other diagnostic results
• When they clearly add specificity to
  diagnosis/conditions documented din physicians
  note

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Inappropriate application of Diagnostic Tests

• Microbiology report positive for micro-organism
  growth
• No documentation in physicians notes identifying
  diagnosis or treatment for urinary tract
  infection
• CT scan reveals adhesions of the abdomen
• No documentation in physicians notes identifying
  it as the cause of abdominal pain

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Acute on Chronic Condition

• Acute on chronic cholecystitis
• Acute exacerbation of chronic obstructive
  pulmonary disease

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Acute on Chronic conditions

• Where MRDx is both acute/subacute chronic
• If there is no combination code for acute on
  chronic then acute condition should be coded
  first
• The chronic condition is a diagnosis type 3

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Impending or Threatened Condition

• Threatened abortion
• Stage 4 decubitus ulcer. Documentation by
  physician states impending gangrene

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Impending or threatened condition

• If a threatened or impending condition
• Is documented
• Did not occur during the episode of care
• Check the lookup for terminology such as
  impending or threatened under the main term
• If such as index exists assign appropriate code
• If it doesnt exist than the condition described
  as impending or threatened should not be coded
• Code to the precursor condition

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Suspected condition/ Query diagnosis

• Chest pain, Query Myocardial Infarction
• Query Multiple Sclerosis

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Suspected condition/Query Diagnosis

• If no definite diagnosis has been established by
  the end of an episode of health care
• Code the information that permits
• The greatest degree of specificity and knowledge
• The condition that necessitated care of
  investigation

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• If, after an episode of health care, the MRDx is
  still recorded by the physician as suspected,
  questionable, etc and there is no further
  information or clarification
• Code the suspected diagnosis as if it were
  established
• Use the prefix Q in these circumstances
  whenever available.
• If the condition has been ruled out after
  investigation use Z03. Medical observation and
  evaluation for suspected diseases conditions

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• R07.4 (M) Chest pain
• (Q)I21.9(3) Query Myocardial Infarction
• (Q) Query Multiple Sclerosis (M)

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Sequelae

• Late effect of cerebrovascular accident now
  hospitalized for treatment of dysphagia

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Sequelae

• Conditions that are no longer present as the
  cause of a current problem undergoing treatment
  or investigation
• Code the presenting condition as MRDx
• Code the sequelae of the underlying condition
  with a diagnosis type 3

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Admissions from Emergency Room

• Diagnosis of each abstract (emergency inpatient
  record)
• Must accurately reflect the circumstances for or
  treatment provided during that episode of care
• If treatment started in ER and patient was
  admitted
• The identified condition must be recorded as MRDx

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• If no definite treatment for injury or condition
  occurs in the ER
• And no reason is given for why the patient was
  admitted
• Assume that it was for continuation of treatment
  of presenting condition

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Summary of MRDx Rules

• Diagnosis of Equal Importance
• Specificity
• Using Diagnostic Test Results in Coding
• Acute and Chronic Conditions
• Impending or Threatened Conditions
• Underlying Symptoms Or Conditions
• Suspected Conditions/Query Diagnosis
• Sequelae
• Admissions from Emergency Department

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CMG/MCC Assignment

Complexity Levels
RIW
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Diagnosis Typing a 1 digit code

• To indicate the relationship of the diagnosis to
  the patients stay in hospital
• Required for every ICD-10-CA code recorded on the
  Discharge Abstract Database (DAD) (inpatients)
• To differentiate conditions that influence the
  patients stay from those that do not
• To flag post-admission comorbidities
• To use in complexity assignment for CMG