Most Common DRG’s with Recommendations 2018: Part 1

Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer

In 2018, HIA Reviewed 39,828 inpatient records. Even with this large number of records, the DRG’s with recommendations are the ones that coders typically see during audits. This is part 1 of a series as we look at the top 5 DRG’s with recommendations over the next week.

#1 DRG with the most recommendations

DRG 871—Septicemia w/o MV 96+ hours with MCC

For this DRG there were several different DRG’s that were recommended.

The majority of the recommendations from DRG 871 (Septicemia w/o MV 96+ hours with MCC) were to DRG 872 (Septicemia w/o MV 96+ hours w/o MCC) with the recommendation to delete the reported MCC or query for clarification to support the MCC that had been reported.

• Verify that the MCC reported is clearly documented and supported in the medical record. If there’s a chance that the condition is not present or was ruled out, a query is necessary to obtain clarification. When only 1 MCC is present on a record it is always best practice to double check to insure that it can’t be removed in an audit.

DRG 698 (Other kidney & urinary tract diagnosis with MCC) was also the recommended DRG on several cases reviewed. These all required clarification from the MD to support the diagnosis of sepsis or just the re-sequencing of the urinary tract infection to the PDX spot. Not all of these in this DRG required a query.

• Verify that the diagnosis of sepsis is clearly documented and supported before reporting as the PDX. If there is any question at all on this diagnosis, a query should be sent.
• Reasons for queries before reporting sepsis as the PDX may be to clarify if the diagnosis was present on admission or if this was ruled out. Oftentimes coders will see documentation of sepsis after admission. Even if the clinical indicators are present at the time of admission, if the diagnosis isn’t made until later in the stay a query is needed.
• Another common documentation issue that coders see is sepsis and bacteremia being used in the medical record interchangeably and then the discharge summary is completed with only bacteremia. Coders should obtain further clarification from the physician to determine if sepsis was ruled out and the patient only has bacteremia or if sepsis was present for this patient.

The third most recommended change was to DRG 853 (Infection & parasitic diseases with O.R. procedure with MCC) with the addition of PCS code that may or may not have required a query. This one is a huge difference in reimbursement.

• Coders should review the entire medical record to look for procedures that were performed. There may not be a formal operative note in the record however, the orders and progress notes should give the coder a clue to look further or query the physician.

Another common finding within the records reviewed for DRG 871 is missing or incorrect reporting of mechanical ventilation. The coder should know where to find the mechanical ventilation sheets and “best practice” is to double check vent times in a patient with sepsis as the PDX. Missing or incorrectly reporting is a huge difference in reimbursement.

Be on the lookout for Part 2 of this series tomorrow!

Happy Coding!

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.