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MS-DRGs

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  1. MS-DRGs Kiwi-Tek Webinar Session 1 August 2009 Joy King, RHIA, CCS Karen Scott, MEd, RHIA, CCS-P, CPC Joy King Consulting, LLC

  2. Specificity Matters!! • Problematic Clinical Diagnoses: • CHF (systolic vs. diastolic, acute/chronic) • Sepsis/SIRS (sepsis vs. bacteremia, severe, organ failures linked) • Respiratory Failure (acute/chronic, underlying cause) • DM (manifestations/complications, Type1 or 2) • Chronic Kidney Disease (stages) • Pneumonia (link to organism or aspiration) • CAD (chest pain vs. angina vs. CAD) • Decubitus (stage, POA) • GI bleed linked to GI cause • Malnutrition (severity) • Increased queries for severity & POA indicators Joy King Consulting, LLC

  3. CHF Failure of the heart to pump blood adequately to other parts of the body. It can result from any structural or functional cardiac disorder that impairs the ability of the heart to fill with or pump sufficient blood out. It occurs when the flow of blood from the heart (cardiac output) decreases or fluid backs up behind the failing ventricle or both. Left-sided failure usually precedes right-sided failure. Joy King Consulting, LLC

  4. Framingham Criteria for CHF Major • Paroxysmal nocturnal dyspnea • Jugular venous distension • Rales • Cardiomegaly on CXR • Acute pulmonary edema • S3 gallop • Elev CVP (>16 cm H2O) • Hepatojugular reflux Minor • bilateral ankle edema • Nocturnal cough • DOE • Hepatomegaly • Pleural effusion • Decrease vital capacity by 1/3 • Tachycardia (>120) 2 major or 1 major + 2 minor Joy King Consulting, LLC

  5. CHF NY Heart Association Classification • Class I = asymptomatic • Class II = symptoms w/ mod exertion • Class III = symptoms w/ min exertion • Class IV = symptoms at rest Joy King Consulting, LLC

  6. CHF Documentation Systolic Failure (abnormal contractility) • Heart contracts less strongly than normal • Affects ability to pump blood out into body • Decreased Ejection fraction (< 40%) Diastolic Failure (abnormal filling) • Heart muscle stiff & cannot fully relax • Prevents heart from fully filling up w/ blood, which causes fluid to back up in tissues • Ejection fraction may be normal (> 45-50%) Joy King Consulting, LLC

  7. CHF Treatment • Smoking cessation • Weight loss • Low-saturated diet • Coreg, Lanoxin, Lasix or Bumex, ACE-inhibitors (“pril” drugs, e.g. Catapril, Lisonopril), angiotensin receptor blockers (“sartan” drugs), nitroglycerin, calcium channel blockers, alpha blockers, beta blockers (“olol” drugs, e.g. Atenolol) Joy King Consulting, LLC

  8. Acute Exacerbation of CHF • Pt on tx for chronic failure w/ immediate need to increase meds • Recent increase in symptoms—pulmonary edema for left side, pedal edema for rt side • Elevated pro-BNP—this depicts CHF accurately 83% time per Am Jrnl Cardiology < 100 = no CHF > 300 = mild CHF > 600 = moderate CHF > 900 = severe CHF Joy King Consulting, LLC

  9. CHF Codes • Acute Systolic Heart Failure 428.21 MCC • Acute Systolic & Diastolic Heart Failure 428.41 MCC • Acute on Chronic Systolic Heart Failure 428.43 MCC • Acute Diastolic Heart Failure • 428.31 MCC • Acute on Chronic Diastolic Heart Failure 428.33 MCC • Left Heart Failure 428.1 CC • Systolic Heart Failure NOS 428.00 CC • Chronic Systolic Heart Failure 428.22 CC • Chronic Diastolic Heart Failure 428.32 CC • Systolic & Diastolic Heart Failure 428.40 CC • CHF 428.0 NON CC • HEART FAILURE 428.9 NON CC Joy King Consulting, LLC

  10. CHF Scenario • PDx billed as 428.0 CHF • DS diagnoses: bilateral pneumonia, COPD, CHF, chronic respiratory failure on home O2, smoker, obesity • CHF not documented in H&P or PN • Only "mild CHF" noted on CXR • Correct PDx? Joy King Consulting, LLC

  11. Sepsis Coding Definitions • Bacteremia = + blood cultures (CC) • Urosepsis = UTI (CC) • Septicemia = + BC w/ a systemic symptom, e.g. fever (038x – MCC) • Sepsis = SIRS due to infectious process w/o organ dysfunction (038x + 995.91, 2, 4 – MCCs) • Severe Sepsis = SIRS w/ organ dysfunction • Septic Shock = Severe sepsis w/ hypotension unresponsive to IV fluids—BP < 90, needs Dopamine Joy King Consulting, LLC

  12. Sepsis • S/S: chills, skin eruptions, fever, nausea, leukocytosis, vomiting, diarrhea, altered mental status • Lab findings: + BC, WBC 15,000 – 30,000 w/ left shift; platelet count decreased; BUN & Cr elevated • Common BC contaminant is Staph epidermis Joy King Consulting, LLC

  13. Sepsis • SIRS criteria: (Not the infection itself but the response to the infection) • Temp > 100.4 or < 96.8 F • WBC > 12,000 or < 4,000 or left shift > 10% immature bands • Heart Rate > 90 beats/minute (tachycardia) • RR > 20 or PaCO2 < 32 (tachypnea) • Clearly document WHEN sepsis developed if known Joy King Consulting, LLC

  14. Severe Sepsis (995.92) • Multi-system Organ failure (MODS) • SIRS infection w/ acute organ failure • 2 or SIRS criteria w/ organ dysfunction, e.g. renal or respiratory failure, altered mental status, encephalopathy, metabolic acidosis, etc. • MD needs to specify failed organs, link to sepsis--most are MCCs • Septic shock—Severe sepsis + CV failure • MD needs to specify septic shock Joy King Consulting, LLC

  15. Septic Shock • S/S: hypotension; fever; abrupt onset of chills, N&V, diarrhea, extreme exhaustion (prostration) • EKG may show conduction defect or V fib • Lab findings may include elevated Bun, Cr, leukocytosis or neutropenia, urine w/ + nitrates • CXR may show pulmonary edema • Tx: Dopamine & IV abx Joy King Consulting, LLC

  16. Scenario • Pt admitted w/ Pneumococcal pneumonia, neg BC, temp 103, WBC 17,000 w/ 20% bands. Tx w/ abx, IV fluids. • Is PDx Pneumococcal Pneumonia or Sepsis? PneumoniaSepsis 193 w/ MCC – 1.4327 871 w/ MCC – 1.8222 ($7343)($9339) 194 w/ CC – 1.0056 195 w/o CC – 0.7316 Joy King Consulting, LLC

  17. Sepsis Scenario • PDx billed as Streptococcal Sepsis 038.0 • Bacterial Endocarditis (421.0) billed as secondary diagnosis • H&P, PN, & DS document infected pacemaker wires, resulting in endocarditis & sepsis. Patient was not a surgical candidate due to debilitated condition, so was treated w/ long-term IV antibiotics. PDx correct? PDx 038.0 DRG 871 0.8959 PDx 996.61 DRG 314 0.9025 Joy King Consulting, LLC

  18. Acute Respiratory Failure • Inadequate exchange of oxygen/CO2 by lungs • Difficulty breathing, e.g. rapid RR, use of accessory muscles of respiration • ABG values including: PaO2 < 60, PCO2 > 50, pH < 7.30—2 of 3 of these diagnostic of respiratory failure. NOTE: These values must be adjusted based on baseline values for a COPD patient—pH more useful in COPD patients • Document underlying cause of respiratory failure Joy King Consulting, LLC

  19. Chronic Respiratory Failure 1 of 2 criteria: • Hypoxemia – PaO2 < 60, usually on home oxygen • Hypercapnia – PaCO2 > 50 • If patient has respiratory distress, O2 falls more than 10-15 mm Hg, or pH < 7.30, then patient in ACUTE respiratory failure • “Acute” assumed to be present if patient on vent or BiPAP, but must be documented by MD Joy King Consulting, LLC

  20. Respiratory Failure • Causes: pulmonary edema, ARDS, sepsis, pneumonia, acute lung injury, pulmonary fibrosis, pulmonary embolus, CHF, COPD, asthma, pneumothorax, stroke, myasthenia gravis, ALS • Treatment: Inotropic drugs (Norepinephrine, Dopamine, Dobutamine; bronchodilators (Albuterol, Ephedrine, Proventil, Ventolin, Theo-dur, Aminophylline); intubation; positive pressure breathing (CPAP, BiPAP), O2 therapy Joy King Consulting, LLC

  21. Respiratory Failure Coding Issues • Clinical findings vary greatly from patient to patient • Inadequate documentation to determine if in an acute phase of respiratory failure or a chronic form of pulmonary disease • Unclear documentation of underlying cause to determine sequencing Joy King Consulting, LLC

  22. Respiratory Failure • 518.81 Acute Respiratory Failure = MCC • 518.84 Acute & Chronic Resp Failure = MCC • 518.82 Other pulmonary insufficiency = CC • 518.83 Chronic respiratory failure = CC Joy King Consulting, LLC

  23. Respiratory Failure—MS-DRG Options • 177 Resp infect w/ MCC 2.0393 • 178 Resp infect w/ CC 1.4983 • 179 Resp infect w/o CC 1.0419 • 189 Pulm edema & resp failure 1.3488 • 190 COPD w/ MCC 1.3030 • 191 COPD w/ CC 0.9757 • 192 COPD w/ CC 0.7254 • 291 Heart failure w/ MCC 1.4601 • 292 Heart failure w/ CC 1.0069 • 293 Heart failure w/o CC 0.7220 Joy King Consulting, LLC

  24. COPD Irreversible chronic lung condition which obstructs air flow. Usually includes combination of emphysema & chronic bronchitis • S/S: increased SOB, increased cough/sputum production, respiratory distress or failure, CO2 retention, low O2 sats, respiratory infection, diaphoresis, tachycardia • Tx: beta agonists (Albuterol, Proventil, Ventolin, Atrovent, Prednisone, Medrol) • Look for BiPAP, CPAP, home O2 NOTE: Acute cor pulmonale often occurs in COPD patients w/ acute respiratory infections Joy King Consulting, LLC

  25. COPD Acute Exacerbation treated the same as COPD: abx, bronchodilators, liquification, evacuation of secretions, O2, IV corticosteroids to reduce respiratory symptoms Progression of COPD ranges from: • Patients w/ decompensation & increased sputum production only • Patients w/ severe dyspnea or purulent bronchitis • Patients whose efforts to expectorate sputum complicated by bronchospasm Joy King Consulting, LLC

  26. COPD Coding Issues • Clinical findings vary greatly depending on stage of the disease • Distinguishing an “acute, reversible” process from an “acute exacerbation” of an underlying irreversible disease process Joy King Consulting, LLC

  27. COPD CCs • 491.21 w/ acute exacerbation • 491.22 w/ acute bronchitis • 493.01 extrinsic asthma w/ status asthmaticus • 493.02 extrinsic asthma w/ acute exacerbation • 493.11 intrinsic asthma w/ status asthmaticus • 493.12 intrinsic asthma w/ acute exacerbation • 493.21 chronobstr asthma w/ status asthmaticus • 493.22 chronobstr asthma w/ acute exacerb • 493.91 asthma w/ status asthmaticus • 493.92 asthma w/ acute exacerbation Joy King Consulting, LLC

  28. Diabetes Mellitus Uncontrolled DM: NOT a CC • Multiple BS > 250 requiring changes in tx • One fasting BS > 300 • Recurrent hypoglycemia, multiple changes in tx • Hgb A1c > 7 Joy King Consulting, LLC

  29. Diabetes Mellitus Look for complications of DM 250.4x DRG 700 0.6828 250.5x DRG 125 0.6689 250.6x DRG 74 0.8423 250.7x DRG 301 0.6606 250.0,1,2,3,8,9x DRG 639 0. 5598 NOTE: 250.4x – 250.9x NOT CC HOWEVER, Manifestation codes that are CCs • 337.1 autonomic neuropathy in other diseases Look for tx w/ Viagra or orthostatic hypotension • 344.61 neurogenic bladder • 585.4 or 585.5 CKD, stages 4 or 5 Joy King Consulting, LLC

  30. Diabetic Ketoacidosis • 250.1x (MCC)—per CC 2 Q 06, p 19, DKA is “uncontrolled” and default type I unless MD specifies type II. • Ketoacidosis from complete lack of insulin & excessive counter-regulatory hormone excess • Hyperglycemia (300-600 BS), excess liver production, decreased peripheral cell uptake, ketosis—leads to acidosis Joy King Consulting, LLC

  31. Diabetic Ketoacidosis Signs/symptoms: • Severe dehydration, Kussmaul breathing, fever, possible coma, N&V, polydipsia, tachycardia, elevated BUN, lethargy, “fruity” breath, hypotension, headache Treatment: • Rapid IV fluid tx • IV insulin • 250.3x Diabetic w/ other coma (MCC) Joy King Consulting, LLC

  32. Diabetic w/ Hyperosmolar Coma 250.2x (MCC) • Primarily in type II DM—just enough insulin to prevent ketoacidosis but not enough to prevent hyperglycemia • Profound dehydration, hyperglycemia (BS usually > 600), hyperosmolality (330-380) • Tx w/ rehydration w/ isotonic/hypotonic saline & small doses insulin, removal of underlying cause • *Uncontrolled DM, but unlike DKA, MD must state “uncontrolled” to code it Joy King Consulting, LLC

  33. Diabetes Mellitus • If the type is unspecified or IDDM stated, code to Type 2 • If type 2 diabetics are on long-term insulin use, add V58.67. That should not be coded if sliding scale insulin temporarily used during the stay to keep BS under control • Manifestations (PVD, neuropathy, ulcers) should be linked to DM—also specify whether DM or HTN is underlying cause of renal problems • “Uncontrolled” vs. “Hyperglycemia” in DM Joy King Consulting, LLC

  34. Osteomyelitis Scenario • PDx billed as 250.80 + 730.27 Diabetic Osteomyelitis • Patient has severe PAD/PVD documented w/ no link to DM. DM rarely documented in PN. • Patient had bilateral occluded SFA—attempts to pass wire failed • PNs document patient had gangrenous ulcers on heels, documented as pressure ulcers • Patient underwent excisional debridement down to the bone. Correct PDx? PDX 250.80 DRG 622 1.3628 PDx 730.17 DRG 463 1.4570 Joy King Consulting, LLC

  35. Diabetic Nephropathy Glomeruli show thickening of basement membrane, mesangialnodularity & “sclerosis”—accumulations of acellular protein called “Kimmelstiel-Wilson nodules” • Code 250.4x (not a CC) + manifestation code • Diabetic nephropathy 583.81 (NOT a CC) • Diabetic nephrosis 581.81 (CC) (intercapillaryglomerulosclerosis, Kimmelstiel-Wilson syndrome) Look for 4+ protein on U/A, low serum albumin Joy King Consulting, LLC

  36. Kidney Disease Definitions • Acute Renal Failure (MCC): sudden reduction of kidney function, within hours or days—may be transient or lead to chronic renal failure • Chronic Kidney Disease (Stage IV, V CCs): progressive loss of kidney function that develops gradually due to several diseases such as DM, HTN, obstructive uropathy, etc. • Chronic Renal Insufficiency (not a CC): loss of renal function incomplete—more abnormal lab findings. Treatment to avoid or delay progression to renal failure • ESRD (MCC): loss of renal function complete—abnormal lab & clinical findings Joy King Consulting, LLC

  37. Acute Renal Failure • Present in 1-5% of all hospitalized patients and up to 20% of ICU patients • Characterized by rapid decline in GFR (hrs – wks) & retention of nitrogenous waste • Creatinine will be > 1.5 or > 50% increase over baseline, e.g. if normal is 1.2, Cr must increase to 1.8 to indicate ARF • “Acute renal injury” new term Joy King Consulting, LLC

  38. Acute Renal Failure • Pre-Renal: kidney doesn’t get enough blood; cause of 55% of ARF; # 1 cause is dehydration; also caused by CM, valvular heart disease, sepsis, pulmonary embolism • Intra-Renal: dz of renal parenchyma; cause of 40% of cases; caused by renal artery obstruction, glomerulonephritis, ATN, etc. • Post-Renal: acute obstruction of urinary tract; cause of 5% of cases; caused by ureteral calculi, urethral stricture, etc. Joy King Consulting, LLC

  39. Acute Renal Failure Common Lab Findings: • Elevated BUN (nl 8-25 mg/dL) • Elevated Creatinine (nl 0.6-1.5 mg/dL) • Decreased GFR (nl 95-120)(gold standard) • Elevated K • Elevated BP • BUN/Cr ratio > 20 (normal 10) • Elevated spec grav of urine (nl 1.010 – 1.020) • Proteinuria Joy King Consulting, LLC

  40. Acute Renal Failure Things to look for: • Azotemia documented—query MD • Renal insufficiency—query MD • Dehydration • Elevated troponins w/o MI • Low urine output • >30-50% rise in BUN/Cr • Is it resolving w/ fluids? • Arrhythmias on EKG due to electrolyte imbalances Joy King Consulting, LLC

  41. Renal Insufficiency A non-specific term that indicates decrease in renal function but doesn’t really mean anything • Acute (593.9)—not a CC: rise in Cr but doesn’t meet definition for failure • Chronic (585.9)—not a CC: often documented when loss of renal function is incomplete; refer to CKD codes to obtain further specificity Joy King Consulting, LLC

  42. Chronic Kidney Disease Progressive inadequate kidney function resulting from several pathologic processes, such as DM, chronic infection & interstitial nephritis, glomerular dz, HTN, obstructive uropathy. • Kidney damage > 3 months manifest by pathological abnormalities OR abn function tests • GFR < 60 for > 3 months w/ or w/o kidney damage Joy King Consulting, LLC

  43. Chronic Kidney Disease • Signs/Symptoms: oliguria, anuria, elev Cr, hyponatremia, chronic fatigue, chronic peripheral edema, hyperkalemia, normochromic-normocytic anemia, glycosuria, HTN, chronic proteinuria, lung edema/CHF • Treatment: dialysis, fluid balancing w/ liquid intake restriction & renal diet Joy King Consulting, LLC

  44. Chronic Kidney Disease • Stage I Kidney damage with normal or high GFR > 90 Cr < 0.9 585.1 • Stage II Kidney damage with mild decrease in GRF 60-89 Cr 1.0-1.3 585.2 • Stage III Moderate decrease in GFR 30-59 Cr 1.4 – 2.5 585.3 Stages I-III non CCs • IV Severe decrease in GFR 15-29 Cr 2.5 – 4.5 585.4 • V Kidney failure <15 (or dialysis) Cr > 4.5 585.5 • End Stage Renal Disease 585.6 on dialysis HTN chronic kidney disease code each stage HTN/HEART kidney disease Stages IV –V CCs, Stage VI ESRD MCC Joy King Consulting, LLC

  45. MS-DRG Options • Renal Insufficiency vs. CKD vs. Acute Renal Failure group to different DRGs • Renal Failure (acute or chronic) groups to: • MS DRG 682 r.w. 1.6413 • MS DRG 683 r.w. 1.1304 • MS DRG 684 r.w. 0.7305 • Renal Insufficiency groups to: • MS DRG 698 r.w. 1.4718 • MS DRG 699 r.w. 0.9715 • MS DRG 700 r.w. 0.6828 Joy King Consulting, LLC

  46. Scenario Patient admitted w/ secondary diagnosis of CKD. GFR was 29. Query? Joy King Consulting, LLC

  47. Impact on Severity/Reimbursement Patient admitted w/ dysphagia & slurred speech. H&P noted patient also has renal insufficiency PDx: CVA Secondary Dx: Renal Insufficiency MS DRG 66 CVA w/o CC/MCC r.w. 0.8439 $4,325 If MD documents Stage 4 CKD MS DRG 65 CVA w/ CC r.w. 1.1760 $6,027 $1,702 additional reimbursement Joy King Consulting, LLC

  48. Questions? Contact Information: Joy King Consulting, LLC jkinginc@charter.net (205) 612-4471 Joy King Consulting, LLC