Most Responsible Diagnosis & Complexity Coding

1. Most Responsible Diagnosis & Complexity Coding HS317b - Coding & Classification of Health Information

2. MCC 4 Complexity levels CMG RIW

3. Complexity Levels • PLX 1 - no complexity • PLX 2 - complexity related to chronic conditions • PLX 3 - complexity related to serious or important conditions • PLX 4 - highest complexity - complexity related to life-threatening conditions • PLX 9 - complexity & age split are inherent in the CMG so no need for further PLX

4. Complexity 9 • Assigned to • MCC 14 Pregnancy & Childbirth • MCC 15 Newborns & Neonates • MCC 19 Mental Diseases & Disorders • MCC 24 HIV Infections • MCC 25 (CMG 651-659, 674-679 only) Significant Trauma • MCC 99 Ungroupable Data

5. Complexity Assignment • Identifies other diagnoses (other than most responsible diagnosis) which may prolong the length of stay and/or the need for more costly treatment.

6. Resource Intensity Weight • Resource – total hospital service cost including fixed and variable components • Intensity – the amount of service utilized • Weight – relative value of each case compared to the “average case” which is the value of “1”

7. Resource Intensity Weight (RIW) • A statistical cost which recognizes that not every patient consumes the same resources during their stay in hospital. • Resources can differ due to: • Differences in LOS • Types of resources used (medical/surgical) • Nursing intensity, etc.

8. Categories of patients • Typical – patient who receives a fully successful course of treatment in a single institution and is discharge when they no longer require the services of an acute care hospital • Atypical – patient who exhibits a different pattern of care either because they do not complete a successful course of treatment in a single hospital visit or because the LOS is greater than the statistical trim point for CMG/Plx Level (examples: sign-outs, death, transfers, long stay outliers)

9. Comorbidity conditions • Identify other diagnosis to indicate 5 complexity levels - only 465 codes that impact complexity level • Significantly impacts complexity levels and RIWs

10. Comorbidities • All conditions that coexist at the time of admission or develop subsequently & demonstrate • Significantly affects the treatment received • Requires treatment beyond maintenance of the pre-existing condition • Increases the LOS by at least 24 hours

11. How to determine significance? • Documented evidence in physician’s notes/discharge summary that: • Clinical evaluation/consultation document a new or amended course of treatment • Therapeutic treatment/intervention with a code assignment of ’50’ or greater from Section 1 of CCI • Diagnostic intervention, inspection or biopsy with a code assignment from Section 2 of CCI • Extended the LOS by at least 24 hours

12. Post procedural condition • Documented by physician as a complication of the procedure • Present at discharge • Persist post-procedurally for at least 96 hours

13. Valuable tools for coding • Nurses notes • Pathology reports • Laboratory reports • Autopsy reports • Medication profiles • Radiological investigations • Nuclear imaging • etc

14. Comorbid Conditions Identification • A one digit number or letter to identify the relationship of the diagnosis to the patients stay in hospital • Diagnosis type 1, 2, 3, 4, 6, 9, 0, W, X, Y

15. Diagnosis type 1 • Pre-Admit Comorbidity • A condition that existed pre-admission • Satisfies the requirements for determining comorbidity

16. Diagnosis type 2 • Post-admit Comorbidity • A condition that arises post-admission • Satisfies the requirements for determining comorbidity

17. Diagnosis Type 3 • Secondary Diagnosis • A condition or diagnosis which may or may not have received treatment • Does not satisfy the requirements for determining comorbidity • Some codes require a diagnosis type 3

18. Diagnosis type 3 conditions are coded if they are listed on the: • Front sheet • Discharge summary • Death certificate • History & physical • Pre-operative anesthetic consult

19. Diagnosis Type 6 • Proxy MRDx • It is assigned to an asterisk code, the manifestation in a dagger/asterisk convention when it fulfills the requirements stated in the definition of MRDx. • Can only apply diagnosis type 6 to the second line of a diagnosis field of the abstract. • Only one asterisk code is allowed a diagnosis type 6 per encounter.

20. Diagnosis type W, X, or Y • Service Transfer Diagnosis • A diagnosis associated with the first/second/third service transfer • Recording the days spent under another patient service

21. Diagnosis Type 4 Morphology Codes • Morphology codes derived form ICD-O codes describing the type and behaviour of neoplasm

22. Diagnosis type 9 – External Cause of Injury code • Mandatory to use with codes in the range of S00-T98, injury, poisoning and certain other consequences of external causes • Category U98.~, Place of Occurrence • Mandatory with codes in the range of W00-Y34 • Exception Y06 & Y07

23. Diagnosis Type 0 • Use to distinguish babies born via caesarean section from those born vaginally • Application code range is Z38.~ Liveborn infants according to place of birth & P03.4~ Fetus and newborn affected by caesarean delivery

24. Goals for Coding • To distinguish between the diagnosis type categories used in DAD coding/abstracting & correctly apply them • To interpret & apply the Canadian Coding Standards for ICD-10-CA & CCI • To recognize the importance of consistent application of standards to data quality