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Title: MS-DRGs

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

  • 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

  • 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

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

  • 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,
  • Complex Pneumonia Klebsiella, H parainfluenza,
    Legionella, Moraxella, Pseudomonas, S. aureus,
    gram -, anaerobes, aspiration, TB, fungal

  • Look at organism on sputum c/s abx
  • Aspiration PneumoniaClindamycin, Unasyn, Zosyn
  • Gram-negativeZosyn, Gentamicin, Tobramycin,
    Amikacin, Ceftazidine, Ciprofloxacin, Primaxin,
  • S. aureus (including MRSA)Clindamycin, Unasyn,
    Zyvox, Vancomycin
  • EnterococciZyvox, Vancomycin

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

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

  • 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

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
  • II early onset w/ regular activity 413.9
  • III marked limitation of activity 413.9
  • IV angina at rest (angina decubitus) 413.0 (CC)

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

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

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

  • 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

  • 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
  • V flutter 427.42 MCC
  • Tx w/ cardioversion/AICD, IV lidocaine beta
    blocker Amiodarone may be used to suppress V
    tach or V fib

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

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

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

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

Decubitus Ulcers
  • Stage 1 non-blanching erythema (reddened area on
  • 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
  • (Included in CC 4 Q 2008)

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

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

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

GI Disorders
  • CC
  • MCC
  • Diverticulitis
  • Gastric Ulcer
  • Blood in Stool
  • GI Hemorrhage
  • Diverticulitis w/ hemorrhage
  • Diverticulosis w/ hemorrhage
  • Gastritis w/ hemorrhage

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
  • Secondary Dx GI bleed due to gastritis
  • MS DRG 190 COPD w/ MCC r.w. 1.3030 6678

Degree of
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
  • 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
  • 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

Nutritional Status
  • CC
  • MCC
  • Protein-Calorie Malnutrition
  • Malnutrition
  • Cachexia
  • BMI lt19, gt39
  • Severe Malnutrition
  • Severe Protein (Calorie) Malnutrition

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
  • Pneumonia w/ CC DRG 194, 1.0056 5,704
  • Pneumonia w/ MCC DRG 193, 1.43270 8,127

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

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

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,
  • Complications of electrolyte imbalances include
    metabolic encephalopathy, seizures, V tach

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

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

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

  • Acute changes in cognition fluctuating during the
  • Inattention plus
  • Disturbance of consciousness (less clarity)
  • or
  • Altered level of consciousness or disorganized
  • Unlike delirium, mental disorders (dementia,
    etc.) almost never cause inattention or
    fluctuating consciousness

  • 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

  • Pt adm w/ AMS deliriumnot on diuretics. Na of
    118, tx w/ hypertonic saline sent home on fluid
    restriction. Final Dx Delirium due to
  • 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

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

Potential Severity Queries
  • BS gt 100, 200, 500, Hgb A1c gt 7.0uncontrolled
  • 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
  • Elev BS, on steroids and SSIhyperglycemia or DM
    secondary to steroids
  • Chronic drug usequery for dependence
  • Chronic O2 usequery for dependence

Documentation Improvement Tips
  • Use Nurses notes, Wound care notes, PT, OT, ST,
    Nutritional notes to generate information for
  • 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)

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
  • 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

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

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

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.

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?

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

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

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

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?

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
  • w/ query for Acute Renal Failure(MCC) DRG
    177 11,568 7,418 difference

  • Contact Information
  • Joy King Consulting, LLC
  • (205) 612-4471
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