Most Common DRG’s with Recommendations: # 1 DRG 871

We’re finally at the #1 most common DRG with recommendations by HIA for 2019. Just to recap, HIA reviewed over 50,000 inpatient records in 2019. Most have probably already guessed what the correct DRG would be with the most recommendations. There are just some diagnoses and DRG’s that will always be a thorn in the side for coders.

#1 DRG with the most recommendations during HIA reviews 

DRG 871—Septicemia or severe sepsis w/o mechanical ventilation >96 hours with MCC

As stated yesterday, sepsis is and will most likely always be a troubled area for coders. As stated in the sepsis series from November, there are many different criteria being used to diagnose sepsis. That is one of the reasons that it is so difficult to code. However, when we dig in deep to the reasons for the changes in 2019, there is something besides sepsis criteria that is resulting in the recommendations.

The majority (at least 1/3) of the recommendations made to DRG 871 (Septicemia or severe sepsis w/o mechanical ventilation >96 hours with MCC) did not require a physician query and the documentation was available in the record to support the recommendation. More than half of the recommendations were based on selection of PDX being inappropriate. Here are the DRG’s that were recommended for PDX selection (only the ones with many recommendations):

• DRG 698—Other kidney & urinary tract diagnoses with MCC
• DRG 314—Other circulatory system diagnoses with MCC
• DRG 689—Kidney & urinary tract infections with MCC
• DRG 193—Simple pneumonia & pleurisy with MCC
• DRG 917—Poisoning & toxic effects of drugs with MCC

There are many other recommendations that went to different DRG’s based on PDX change, but these were all a single recommendation or a few per DRG.

The next most common recommendation was for deletion of MCC to the account. The majority of these did not require a physician query for clarification in order to delete. These all resulted in a new DRG of 872—Septicemia or severe sepsis w/o mechanical ventilation >96 hours without MCC.

The final reason for recommendations made to records reviewed with DRG 871 was the addition or revision of an ICD-10-PCS code. The majority of these fell into the following DRG’s:

• DRG 853—Infectious and parasitic diseases with O.R. procedure with MCC
• DRG 870—Septicemia or severe sepsis with mechanical ventilation >96 hours

Only a handful of the DRG recommendations based on addition or revision of ICD-10-PCS codes required a physician query. Some of these did not have the mechanical ventilation coded or the time of the mechanical ventilation was counted incorrectly.

What can coders do to improve accuracy of DRG 871?

• Review and verify that the diagnosis of sepsis is accurate at the time of final coding
• Look for causes of sepsis and if there is a link to a device or other complication
• Is sepsis supported? Is a query necessary to clearly document the diagnosis?
• Is the diagnosis of sepsis dropped after admission without clearly ruling out the condition? Query when necessary.
• Is the diagnosis of sepsis documented after admission without clear documentation of the condition being present on admission?
• Are there any chapter specific guidelines that should be followed?
• Was the patient on mechanical ventilation? If so, double check the hours for appropriate reporting
• Does the discharge summary contradict or conflict with the rest of the medical record documentation? When this occurs, it is often necessary to query for clarification.
• Review the medical record for any and all procedures that were performed. If there is anything in the operative note that needs to be clarified that should be completed at the time of coding. Depth of debridement is a very common reason for change based on ICD-10-PCS codes as well as specificity in hours for mechanical ventilation.
• Review the medical record for any past or current conditions and complications. If the documentation is not clear, a query may be needed.

Coders should review the entire medical record to look for any conflicting documentation and clarify this prior to final coding. Clarification prior to final coding will decrease audit recommendations and denials. Remember, denials are costly to the facility with all the time that is spent trying to appeal (see the 5 part Sepsis Series published November 2019). The E-Book on this series can be downloaded on our website here: https://www.hiacode.com/blog/resources/

Recap of most common DRG’s with recommendations in 2019:

• #1. DRG 871-Septicemia or severe sepsis w/o mechanical ventilation >96 hours with MCC
• #2. DRG 872-Septicemia or severe sepsis w/o mechanical ventilation >96 hours without MCC
• #3. DRG 190-Chronic obstructive pulmonary disease with MCC
• #4. DRG 193-Simple pneumonia and pleurisy with MCC
• #5. DRG 853-Infectious & parasitic diseases with O.R. procedure with MCC

Be on the lookout for the top 5 ICD-10-CM/PCS codes for 2019 coming soon.

Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P

References

ICD-10-CM Official Guidelines for Coding and Reporting FY 2020

ICD-10-PCS Official Guidelines for Coding and Reporting FY 2020

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.