Most Common DRG’s with Recommendations 2019: #1
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
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.
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.
This is Part 1 of a 4 part series on the FY2021 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. Here is the breakdown: 72,616 total ICD-10-CM codes for FY2021; 490 new codes (2020 had 273 new codes); 58 deleted codes (2020 had 21 deleted codes); 47 revised codes (2020 had 30 revised codes)
Acute pulmonary edema is the rapid accumulation of fluid within the tissue and space around the air sacs of the lung (lung interstitium). When this fluid collects in the air sacs in the lungs it is difficult to breathe. Acute pulmonary edema occurs suddenly and is life threatening.
“Client S” is a small, not-for-profit, 40 bed micro-hospital in the Southeast. HIA performed a 65-record review this year for Client S and found an opportunity with 15 of them. 9 had an increased reimbursement with a total of $43,228 found.
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.
In the past, there had been an Excludes1 note at I46.- Cardiac arrest that excluded R57.0, Cardiac shock. HIA had also received a letter from AHA on a case in the past that had stated that only I46.- Cardiac arrest would be coded if both were documented. In addition, the Third Quarter Coding Clinic page 26 had a similar case that asked if both could be coded, and AHA had instructed that only I46.9, cardiac arrest, cause unspecified would be coded if both were documented and that the CDC would be looking at possible revision to the Excludes1 note.
A higher CMI corresponds to increased consumption of resources and increased cost of patient care, resulting in increased reimbursement to the facility from government and private payers, like CMS. We know that documentation directly impacts coding.
Lately we have seen several cases where the endarterectomy was assigned along with the coronary artery bypass (CABG) procedure when being performed on the same vessel to facilitate the CABG. A coronary artery endarterectomy is not always performed during a CABG procedure, so when it is performed it becomes confusing as to whether to code it separately or not.
Assign code Z20.828, “Contact with and (suspected) exposure to other viral communicable diseases” for all patients who are tested for COVID-19 and the results are negative, regardless of symptoms, no symptoms, exposure or not as we are in a pandemic.
The Centers for Medicare & Medicaid Services (CMS) announced new procedure codes for treatments of COVID-19 – effective as of August 1, 2020. Among the new codes are Section X New Technology codes for the introduction or infusion of therapeutics including Remdesivir, Sarilumab, Tocilizumab, transfusion of convalescent plasma, as well as introduction of any other or new therapeutic substances for the treatment of COVID-19.
One common element in many value-based programs is risk adjustment using Hierarchical Condition Categories (HCCs) to create a Risk Adjustment Factor (RAF) score. This method ranks diagnoses into categories that represent conditions with similar cost patterns.
Why are so many AKI records being denied? It’s hard to give one answer for why so many AKI records are being denied lately, but most appear to be due to the multiple sets of criteria available for use in determining if a patient has AKI, as well as physician documentation. As stated in Part 3 of this series, there are three main criteria/classifications used to diagnose AKI.
In previous parts of this series we looked at the definitions of AKI/ARF, causes, coding and sequencing, and the common clinical indicators that patients present with that are diagnosed with this condition. In Part 4, we will look at the documentation that should be present to report the diagnosis without fear of denial, as well as when a query is needed to clarify the diagnosis.
If the facility does a COVID-19 test, and test is negative, do I need a diagnosis code. The answer is yes, you will report a Z-code. The Z-code depends on the record documentation and circumstances of testing. For any patient receiving a COVID-19 test, if negative, there MUST e a Z-code to describe why the test was taken. (Test negative for COVID-19 and MD does not override negative results).
In the first parts of this series we looked at definitions of AKI/ARF, causes, coding and sequencing. In Part 3, we will look at what clinical indicators would possibly be present to support the diagnosis of AKI/ARF.
The FY2021 IPPS Proposed Rule is out and here are some highlights from it regarding ICD-10 Code proposals. We will know if these changes are permanent after the public comment period is over on July 10, 2020 and CMS prepares the Final Rule, usually out by August 1.
As discussed in Part 1 of this series, AKI/ARF is a common diagnosis that coders see daily. In Part 2, we are going to focus on the different types/specificity of AKI/ARF. We’ll learn what they mean, as well as how to code the diagnosis.
This is part 1 in a series focused on coding of acute kidney injury (AKI) and/or acute renal failure (ARF). AKI/ARF is reported often, but is also one of the most common diagnosis found in denials.
With the proliferation of COVID-19 cases, we thought we would put together a quick reference listing of some of the common scenarios that coders have asked about. As with all coding, coders should follow Official Guidelines for Coding and Reporting and the COVD-19 Frequently Asked Questions document by the AHA.
Effective March 1, Medicare will pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19. This great for providers whose patients are reluctant to visit the office.
The biggest reasons why some hospital systems are moving to single path coding is to eliminate duplicative processes and to optimize productivity. In addition, costs are reduced when only one coder “touches” the record and completes both types of coding.
Effective with 4/1/2020 discharges, ICD-10-CM code U07.0 is used to report vaping -related disorders. ICD-10-CM code U07.0 (vaping related disorder) should be used when documentation supports that the patient has a lung-related disorder from vaping. This code is found in the new ICD-10-CM Chapter 22. U07.0 will be in listed in the ICD-10-CM manual under a new section: Provisional assignment of new disease of uncertain etiology or emergency use.
The US government and public-health officials are urging consumers to utilize telemedicine for remote treatment, fill prescriptions and get medical attention during the new coronavirus pandemic. The goal is to keep people with symptoms at home and to practice social distancing if their condition doesn’t warrant more intensive hospital care.
Coronavirus: Tips for working from home. Companies around the world have told their employees to stay home and work remotely. Whether you’re a new to this concept or a work from home veteran, here’s some tips to staying productive from our #HIAfamily.
This is part two of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. In this part, we discuss mismatches and how to best go about resolving them. In part three we will provide a case example of best practice interaction.
This is part one of a three part series in which we address how coders can better interact with Clinical Documentation Integrity (CDI) professionals. Many times these departments are separate and the remote environment makes it difficult to interact efficiently between the two departments. In part one, we will discuss the history and objectives of CDI so the coder has a better understanding of CDI’s role.
One reason that coders should report chronic conditions (including history and status codes) on outpatient records is the HCC’s—Hierarchical Condition Categories. The quick and easy explanation of what HCC’s are is each HCC is mapped to certain ICD-10-CM codes or code ranges. HCC coding is designed to estimate future health care costs for patients.
For Part 5 of this 5-part series, we will look at Chapter 4 within ICD-10-CM—E00-E89—Endocrine, Nutritional, and Metabolic Diseases. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 4 of this 5-part series, we will look at Chapter 10 within ICD-10-CM—J00-J99—Diseases of the Respiratory System. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 3 of this 5 part series, we will look at Chapter 9 within ICD-10-CM—I00-I99—Diseases of the Circulatory System. This chapter contains so many of the everyday diagnoses that we code such as hypertension, heart disease and stroke.