MS-DRGs

1
MS-DRGs

• Kiwi-Tek Webinar
• Session 2
• August 2009
• Joy King, RHIA, CCS
• Karen Scott, MEd, RHIA, CCS-P, CPC

2
Pneumonia

• 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

3
Pneumonia

• 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

4
Healthcare-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

5
Pneumonia

• 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

6
Pneumonia

• 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

7
Aspiration 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

8
MS-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

9
Pneumonia

• 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

10
CAD 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)

11
CAD 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

12
Acute 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

13
MI 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

14
Arrhythmias

• 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

15
Arrhythmias

• 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

16
Heart 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

17
Complete 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

18
Chest 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

19
Decubitus 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

20
Decubitus 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)

21
Coding 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

22
Pressure 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

23
Sequencing 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

24
GI Disorders

• CC

• MCC

• Diverticulitis
• Gastric Ulcer
• Blood in Stool
• GI Hemorrhage

• Diverticulitis w/ hemorrhage
• Diverticulosis w/ hemorrhage
• Gastritis w/ hemorrhage

25
Impact 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)

26
Degree 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
27
Malnutrition

• 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

28
Nutritional Status

• CC

• MCC

• Protein-Calorie Malnutrition
• Malnutrition
• Cachexia
• BMI lt19, gt39

• Severe Malnutrition
• Severe Protein (Calorie) Malnutrition

29
Malnutrition 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

30
Impact 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

31
Impact 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

32
Electrolyte 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

33
Hyponatremia

• S/S mainly from CNS dysfunction
• Headache
• Confusion
• Stupor
• Can lead to seizures, coma death

34
Altered 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

35
Metabolic 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

36
Delirium

• 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

37
Delirium

• 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)

38
Scenario

• 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

39
Reflection 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

40
Potential 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

41
Documentation 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)

42
Physician 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

43
Physician 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

44
How 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

45
How 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.

46
How 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?

47
Physician 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

48
Pneumonia 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

49
Acute 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

50
AMS 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?

51
Query 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

52
Questions?

• Contact Information
• Joy King Consulting, LLC
• jkinginc_at_charter.net
• [phone]