Medicare SeverityDiagnosis-Related Groups

Bunnie Cobb, RHIT, CCS

EOHIMA - September 22, 2007

New DRG SystemVersion 25

Biggest change to DRGs in 24 years RAND study winner More accurately groups severity of

illness (resource intensity) and payment Reduces incentives to specialty hospitals CMS committed to MS-DRGs

RAND Comparison

RAND Comparison continued

MS-DRGs

Uses CMS DRGs as foundation Consolidated current DRGs into base DRGs Made no changes to MDCs 14 and 15

(obstetrics and newborns) Eliminated:

Low volume DRGs Age-related DRGs

Increase in layers (subgroups)

Types of MS-DRGs

Examples of DRG Groups

MS-DRG MS-DRG Title

   

009 Bone marrow transplant

   

131 Cranial/facial procedures w CC/MCC

132 Cranial/facial procedures w/o CC/MCC

   

175 Pulmonary embolism w MCC

176 Pulmonary embolism w/o MCC

   

177 Respiratory infections & inflammations w MCC

178 Respiratory infections & inflammations w CC

179 Respiratory infections & inflammations w/o CC/MCC

Microsoft Excel Worksheet

CCs - The bad news

Removed >449 codes from the CC list Some of our most commonly coded conditions,

i.e. CHF, COPD, dehydration, atrial fibrillation Penalized for nonspecific diagnoses

CHF unspecified = not a CC Chronic diastolic or systolic CHF = CC Acute diastolic or systolic CHF = MCC

V24 cases had at least one CC 77.6% of the time, under V25 this will be reduced to 40.34%

Microsoft Excel Worksheet

CCs - The Good News ?

Previous reduction of codes on CCs list in 2006 from 3,326 to 2,583…

Now there are 4,922 codes that are either a Major CC or a CC: Major CC 1,580 codes CC 3,342 codes

Microsoft Excel Worksheet

Only a CC if Patient Discharged Alive

427.41, Ventricular fibrillation 427.5, Cardiac arrest 785.51, Cardiogenic shock 785.59, Other shock without mention of trauma 799.1, Respiratory arrest

Financial Impact $ $ $

CMS increased IPPS sum by 3.3% Reduction of RWs by 4.8% over 3

years to account for expected coding improvements

1.2% FY08 1.8% FY09 1.8% FY10

OROR ??????

What to Expect

Extreme scrutiny of Case Mix

More physician queries

+ Delays in billing

= More pressure on coders

How to Prepare

Learn the new rules Make the CC/MCC list your friend Review all query forms Plan when to query Educate yourself clinically Work with clinicians for more specific

documentation

References

AHIMA’s CoP for Inpatient Coding @ ahima.org

CMS website for IPPShttp://www.cms.hhs.gov/AcuteInpatientPPS/

CMS Adopts DRG Overhaul in IPPS Final Rule, 8/10/07http://health.cch.com/news/medicare/081007a.asp

Journal of AHIMA: Severity-Adjusted DRGs for FY 2008? July 2007Positioning Your Facility for Severity Adjusted Coding, April 2007