Secondary Effects of APR‐DRG Assignments - acdis.org · •CMS adopted the DRG system in the...

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This is the Full Title of a Session

Secondary Effects of APR‐DRG Assignments

Candace Blankenship, BSN, RN, CCDSClinical Documentation Improvement SpecialistJohns Hopkins Health SystemMaryland ACDISBaltimore, MD

2018 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:– Identify the coding tools embedded in the 3M™ encoder– Identify three ways APR‐DRG coding interacts within the patient coding profile

– Build specific coding profiles for the major primary DRGs in their practice

– Discuss and educate their peers in quality and finance regarding the nuances of ROM scoring in the APR‐DRG system


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Polling Question #1

• Who here loves APR‐DRG?– Heck yeah I do!– Love is a strong word. Maybe like?– Not me!


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Why We Use APR‐DRG


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Our History

• The DRG system– Created at Yale University in the 1970s by Robert Fetter and John Thompson

– Contained 467 groups– Used to describe diagnoses and conditions and their subgroups (think CHF, acute CHF, and acute systolic CHF)

– The goal of this program was to move the U.S. from a “cost‐based” to a “product‐based” reimbursement system

Savage, Leah (Ed.). (2017). Pediatric CDI: Building Blocks for Success. Middleton, MA: HCPro.


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Our History

• CMS adopted the DRG system in the early 1980s and split it into 2 groups: MS‐DRG and AP‐DRG– MS‐DRG

• Used to bill and reimburse for services rendered to the Medicare recipient

• The MS‐DRG system requires that the individual Medicare patient be assigned a diagnosis code that describes the principal reason for the hospital admission, which then triggers the assignment of a relative reimbursement weight (RW) and a length of stay (LOS) parameter

• The MS‐DRG coding system allows the hospital to further describe the Medicare patient for reimbursement purposes if a MCC or CC occurs sometime during the admission



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Our History

MS‐DRG 293 HF w/o MCC/CC RW 0.6618 ALOS 3.0

MS‐DRG 293 HF w/CC RW 0.9574 ALOS 4.3

MS‐DRG 293 HF w/MCC RW 1.4796 ALOS 5.8


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Our History

• APR‐DRG– Created through a collaboration between 3M™ Health Information Systems and the National Association of Children’s Hospitals and Related Institutions (NACHRI)

– The goal of this collaboration was to expand the old AP‐DRG coding system to include diagnoses and conditions that were specific to pediatric patient populations

– APR‐DRG considers the patient’s age, sex, birth weight, discharge status, primary cause for admission, and as many secondary diagnoses that are needed to describe the patient’s current state of health*

*Medicare only accepts lines 2–25 from your coding profileSavage, Leah (Ed.). (2017). Pediatric CDI: Building Blocks for Success. Middleton, MA: HCPro.


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Our History

• APR‐DRG (cont.)– Just like MS‐DRG, the APR‐DRG system assigns a relative

reimbursement and a LOS parameter, but it also assigns a severity of illness (SOI) and a risk of mortality (ROM) score

– The SOI and ROM are scored by severity level:• 1 Minor• 2 Moderate• 3 Major• 4 Extreme

– The SOI and ROM that is calculated by the APR‐DRG system provides a way to measure the healthcare provider’s complicated patient population



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Our History

The patient scores in the APR‐DRG system:APR‐DRG 194 HF RW 1.8244 LOS 8.76

SOI 4 ROM 4

End‐Stage CHFAcute‐on‐chronic systolic heart failure, cardiogenic shock, NSTEMI 2, NSVT, mixed acid‐base balance, CKD 4

The patient scores in the MS‐DRG system:MS‐DRG 293 HF w/MCC RW 1.4796 LOS 5.8


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The APR‐DRG Encoder

In a Relationship


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194 Heart Failure

MD APR DRG and MDC Information

Click to open all of your “+” boxes to change them to “‐” boxes

3M™ APR‐DRG ReportPOA SOI/ROMDischarge SOI/ROMLogic Paths

Advanced Session ReportMS‐DRG APR‐DRGAnalyzer SummaryDiagnosis Code DetailProcedure Code Detail


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I5023 Acute on chronic systolic heart failure

Diagnosis Code Detail

Codebook Coding Cl Coding HB CDI HCC

The selected codeCode alsoExcludes notesOther codes in that subgroup

Any Coding Clinic that mentions the selected dx code

ICD‐10 focusedOther dxsDefinitions

Clinicaldocumentationconcepts

HierarchicalConditionCategory


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Add Diagnosis

Add Procedure

Codebook

Direct Code

DRG Options

Analyze

Complete

Diagnosis suggestions to consider

MSRP

If you leave your “Nosology Messages/Edits” box open,there is a lot less clicking on this button


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The Hierarchy of Secondary Diagnoses in the APR‐DRG Encoder

Secondary Diagnosis With the Highest

Rank

Secondary Diagnoses That Impact SOI/ROM

The Remaining Secondary Diagnoses That Have No Impact on SOI/ROM


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SOI ROM CODE

P P I5023 Acute‐on‐chronic systolic heart failure

3 3 N179 Acute kidney failure

2 3 R64 Cachexia

1 1 E785 Hyperlipidemia

1 1 Z66 DNR

The SOI and ROM scores are underlinedThe SOI and ROM scores will IMPACT the principal DRG score

Only the ROM score is underlinedOnly the ROM score will IMPACT the principal DRG scoreThe SOI score will NOT impact the principal DRG score


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IMPACT

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This Is Your ONE THING!


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APR‐DRG Coding Profiles Used in This Presentation• All of the coding profiles use a >70‐year‐old patient

demographic.• All of the coding profiles were built to focus on the ROM‐

level scoring. • The rules for level assignment used in this presentation can

be applied to SOI‐level scoring as well.• I used abbreviations in the coding profiles to save space, so

when you see “AKI,” I intend for you to think “acute kidney injury.” Do not query me!

• I did not list combination codes (hypertensive heart disease) in the presentation’s coding profiles, but they were included when I tested these scenarios. The combination codes do not add value to the SOI or ROM, but they do better describe the complexity of the patient.


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It’s Not You, It’s Me


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It’s all about relationships.


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1. The Relationship Between the Patient’s Ageand the Assigned ROM Level

SOI ROM 3‐year‐old female

3 4 A419 Sepsis

2 2 J189 Pneumonia

4 3 N179 AKI

3 4 R6521 Severe sepsis

with shock


3 3 A419 Sepsis

2 2 J189 Pneumonia


with shock

3 3 N179 AKI


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3 3 A419 Sepsis

2 2 J189 Pneumonia


with shock

3 2 N179 AKI


3 3 A419 Sepsis

2 2 J189 Pneumonia


with shock

3 2 N179 AKI


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3 3 A419 Sepsis

2 2 J189 Pneumonia


with shock

3 2 N179 AKI


3 4 A419 Sepsis

2 3 J189 Pneumonia


with shock

3 3 N179 AKI


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3 4 A419 Sepsis

2 3 J189 Pneumonia


with shock

3 3 N179 AKI


3 4 A419 Sepsis

2 3 J189 Pneumonia


with shock

3 3 N179 AKI


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• The impact of age is seen more in the ROM level than it is for the SOI level

• < 1 year of age Congenital conditions, low birth wgt• > 65 years of age Afib, COPD, nephritis, acidosis,

hypotension• > 69 years of age Viral pneumonia, mitral valve

disorder, anemia, specifiedbacterial pneumonia, peritonitis

• > 79 years of age Fracture of femur or pelvis, pleural effusion


3M™ All Patient Refined Diagnosis Related Groups (APR DRG) Methodology Review, Version 35, Oct 2017


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AIDS

ESRD

Medicare is not just for the elderly.

Younger adults with permanent disabilities



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2. The Relationship Between the Assigned SOIand ROM Levels for Each SecondaryDiagnosis

In general, the assigned SOI level will be higher than the assigned ROM level.

There are some exceptions:Acidosis SOI 2 ROM 3DOE SOI 1 ROM 3Oliguria SOI 2 ROM 4Hypotension SOI 2 ROM 3



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3. The Relationship Between the PrincipalDiagnosis and ROM

SOI ROM

2 2 I2109 STEMI


SOI ROM

2 2 J9601 Acute resp failure

SOI ROM

2 2 S225XXA Flail chest

SOI ROM

2 4 I711 Ruptured aortic aneurysm


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4. The Relationship Between a Specific PrincipalDiagnosis and a Secondary Diagnosis

SOI ROM

3 3 A419 Sepsis, unsp organism

3 3 I5023 A on C sys CHF

3 3 N179 AKI

2 3 J189 Pneumonia

2 2 Dehydration

X X R6520 Severe sepsis w/o shock

SOI ROM


4 4 R6520 Severe sepsis w/oshock

3 3 N179 AKI

3 3 J189 Pneumonia

2 3 Dehydration




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Acute systolic CHF• Pleural effusion

• Newborn• Malignant• Due to SLE• Due to heart failure• Other/unspecifiedThe coding pathway for pleural effusion directs you back to the CHF coding pathway.

5. The Relationship Between the Principal Diagnosis and an Associated Secondary Diagnosis



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5. The Relationship Between the Principal Diagnosis and an Associated Secondary Diagnosis

• There is an exception to this rule:

APR‐DRG 190 Acute Myocardial Infarction

Extension of a STEMI

3M™ All Patient Refined Diagnosis Related Groups (APR DRG) Methodology Review Version 35 Oct 2017


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6. The Relationship Between Two Secondary Diagnoses

SOI ROM



3 3 N179 AKI

2 3 J189 Pneumonia

X X R6520 Severe sepsis w/o shock

SOI ROM



3 3 N179 AKI

2 3 J189 Pneumonia

2 2 Dehydration

X X R6520 Severe sepsis w/oshock



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7. The Relationship Between SecondaryDiagnoses in the Same Group

SOI ROM

2 1 J441 COPD exacerbation

3 2 J9611 Chr resp failure

SOI ROM


4 4 J9622 A on C resp failure

3 2 J9611 Chr resp failure



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SOI ROM


4 4 J9601 Ac resp failure

SOI ROM


4 4 J9622 A on C resp failure



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When Rules Converge …

SOI ROM

3 2 S066X94 Traumatic subarachnoid hemorrhage with LOC, initial

4 4 I4901 Vfib

4 4 I469 Cardiac arrest

3 3 I472 Vtach

X X S065X9A Traumatic subdural hemorrhage with LOC, initial

1 1 Z95810 Presence of AICD


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SOI ROM

2 2 I5023 A on C sys HF

3 3 N179 AKI

SOI ROM


2 4 R34 Anuria and oliguria

3 3 N179 AKI



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8. The Relationship Between ROM Level and Non‐OR Procedures

SOI ROM

2 2 I2109 STEMI anterior

SOI ROM

3 4 I2109 STEMI anterior

5A02210 IABP

*SOI

*ROM



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9. The Relationship Between ROM and Z Codes

SOI ROM


3 2 Z95811 Presence of heart assist device



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10. The Relationship Between the Principal Diagnosis and the OR Procedure

SOI ROM

1 1 N08 Glomerular D/O

0TT10ZZ Resection of left kidney

SOI ROM

3 3 N08 Glomerular D/O

0TT20ZZ Resection of both kidneys*SOI*ROM



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SOI ROM

2 1 I25110 CAD w/angina

1 2 I352 AI w/AS

0211093 CABG x 2

SOI ROM

2 2 I25110 CAD w/angina

1 2 I352 AI w/AS

0211093 CABG x 2*SOI*ROM

X2RF032 AVR*ROM



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SOI ROM

4 4 I2109 STEMI

3 3 N179 AKI

5A02210 IABP*SOI*ROM

SOI ROM

3 3 I2109 STEMI

3 3 N179 AKI

5A02210 IABP*SOI*ROM

0212093 CABGAffects secondary DRG



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APR‐DRG MATH for Secondary Diagnoses

DON’T PANIC


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SOI ROM



SOI ROM



4 4 I21A1 NSTEMI 2


4 + 4 = 4


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SOI ROM


4 4 I21A1 NSTEMI 2

3 3 N179 AKI

SOI ROM


4 4 I21A1 NSTEMI 2

3 3 N179 AKI

3 3 I472 NSVT


4 + 3 + 3 = 4


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SOI ROM


4 3 I330 Acute infective endocarditis

4 3 E43 Unsp severe protein malnutrition

3 3 L89154 Pressure ulcer stage 4

SOI ROM


4 3 I330 Acute infective endocarditis

4 3 E43 Unsp severe protein malnutrition

3 3 L89154 Pressure ulcer stage 4

3 3 N179 AKI

3 3 3 3+ + + = 4


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ROM 4

4 + 4 = 4

4 + 3 + 3 = 4

3 + 3 + 3 + 3 = 4


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SOI ROM


4 4 I21A1 NSTEMI 2

SOI ROM


4 4 I21A1 NSTEMI 2

3 3 N179 AKI


4 + 3 = 3


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SOI ROM


3 3 I472 NSVT

SOI ROM


3 3 I472 NSVT

3 3 N179 AKI


3 + 3 = 3


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SOI ROM


2 3 E872 Acidosis

1 2 K760 Fatty liver

SOI ROM


2 3 E872 Acidosis


1 2 N183 CKD 3

3 + 2 + 2 = 3


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ROM 3

4 + 3 = 3

3 + 3 = 3

3 + 2 + 2 = 3


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SOI ROM


4 4 I21A1 NSTEMI 2

4 = 2


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SOI ROM


2 3 E872 Acidosis


3 + 2 = 2


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ROM 2

4 = 2

3 + 2 = 2


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End‐Stage CHF ROM Coding Profile

MCC 4 + 3 4 + 4 4+3+3

Acute cor pulmonale X

CVA X

Acute endocarditis X

AMI X

NSTEMI 2 X

PE X

Aspiration pneumonia X

Respiratory failure X

AKI with ATN X

Cardiogenic shock X


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APR_DRG Analysis

DRG 194 Heart Failure

Weight 1.8244

A LOS 8.76

SOI 4 Extreme

ROM 4 Extreme

MS_DRG Analysis

DRG 293 Heart Failure & Shock (with MCC)

Weight 1.4796

A LOS 5.8

Principal Diagnosis

I5023 Acute on chronic systolic (congestive) heart failure

Secondary Dx SOI ROM

R570 Cardiogenic shock 4 Extreme 4 Extreme

I472 Ventricular tachycardia 3 Major 3 Major

E874 Mixed disorder of acid‐base 3 Major 3 Major

I272 Other secondary pulm HTN 2 Mod 2 Mod

E878 Other d/o of electrolyte bal 2 Mod 2 Mod

K761 Chronic passive liver cong 1 Minor 2 Mod

N183 CKD, stage 3 (moderate) 1 Minor 2 Mod

E871 Hypo‐osmo and hyponatrem 2 Mod 1 Minor

E8342 Hypomagnesemia 2 Mod 1 Minor

I255 Ischemic cardiomyopathy 2 Mod 1 Minor

I248 Other forms of acute ischheart dz

1 Minor 2 Mod

R5381 Other malaise 1 Minor 1 Minor

R600 Localized edema 1 Minor 1 Minor

CHF NYSE Class 4D


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Here’s a Story …


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CODINGPROFILE


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Thank you. Questions?

[email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.


ICD 10 Code Diagnosis Description


E872 Acidosis I110 Hypertensive heart disease w heart failureD684 Acquired coagulation factor deficiency I959 Hypotension, unspecifiedK353 Acute appendicitis with localized peritonitis J84112 Idiopathic pulmonary fibrosisT7611XA Adult physical abuse, suspected, initial C9201 Leukemia, acute myeloblastic, in remissionF1029 Alcohol depend w alcohol induced disorder C9590 Leukemia, unspec not achieved remissionF1019 Alcohol use w alcohol induced disorder D6862 Lupus anticoagulant syndromeD62 Anemia, acute posthemorrhagic A6920 Lyme disease, unspecifiedD6481 Anemia due to antineoplastic chemo F331 Major depressive dis, recurrent, moderateI728 Aneurysm of specified artery CXXXX Malignant neoplasms, primary/metastaticR0681 Apnea, NEC K592 Neurogenic bowel, NECR188 Ascites E6601 Obesity, morbidJ45901 Asthma, unspedified with acute exacerbation I6603 Occlu/stenos bilat middle cerebral arteriesI4891 Atrial fibrillation R34 OliguriaZ68.XX BMI > 40 F1120 Opioid dependence, uncomplicatedG540 Brachial plexus disorders M86622 Osteomyelitis, chronic, left humerusR64 Cachexia K560 Paralytic ileusK8051 Calculous, bile duct G822X ParaplegiaI429 Cardiomyopathy, unspecified M84453A Pathological fracturesL03311 Cellulitis of abdominal wall K766 Portal hypertensionK812 Cholecystitis, acute w chronic cholecystitis F0781 Postconcussional syndromeN18X Chronic kidney disease, stage 4, stage 5 L89XXX Pressure ulcer extremities <stage 4 K9403 Colostomy malfunction I272 Pulmonary hypertensionS060XXX Concussion w LOC unspecified & 31‐59 min I060 Rheumatic aortic stenosisJ449 COPD, unspecified S224XX Rib fractures, multiple, initial visit, closedK50XXX Crohn's disease b377 Sepsis, candidalE848 Cystic fibrosis A400 Sepsis due to streptococcus, group AN3001 Cystitis, acute with hematuria A401 Sepsis due to streptococcus, group BN3000 Cystitis, acute without hematuria A403 Sepsis due to Streptococcus pneumoniaeE860 Dehydration A408 Streptococcal sepsis, otherK57XX Diverticulitis R45851 Suicidal ideationsE1165 DM, Type 2, with hyperglycemia I471 Supraventricular tachycardiaK269 Duodenal ulcer, w/o hemorrahge or perf D696 Thrombocytopenia, unspecifiedR1310 Dysphagia, unspecified E1165 Type 2 DM with diabetic nephropathyI82XXX Embolism, chronic lower extremity K51XX Ulcerative colitisN186 End stage renal disease I8500 Varices, esophageal without bleedingB3781 Esophagitis, candidal B029 Zoster without complicationsR6251 Failure to thrive, child Z codes: K3184 Gastroparesis Z684X BMI > 40K922 GI hemorrhage, unspecified Z781 Physical restraint statusR042 Hemoptysis Z8674 Personal history of sudden cardiac arrestB1710 Hepatitis C, acute without coma Z940 Kidney transplant statusB20 HIV disease Z946 Bone transplant statusE875 Hyperkalemia Z9981 Dependence on supplemental oxygen

Diagnoses by Severity Level APRDRG V34 Severity Level 2 Conditions (Moderate)



K630 Abscess of intestine F332 Major depress dis, recur severe wo psychoticN179 Acute kidney failure, unspecified E440 Malnutrition, moderateE873 Alkalosis E46 Malnutrition, unspecified G931 Anoxic brain damage, not elsewhere classified E8411 Meconium ileus in cystic fibrosisR180 Ascites, malignant D709 Neutropenia, unspecifiedI442 Atrioventricular block, complete K859X Pancreatitis, acuteK5521 AVM intestine, with hemorrhage D61818 PancytopeniaR7881 Bacteremia I309 Pericarditis, acuteK831 Bile duct obstruction J90 Pleural effusion, not elsewhere classifiedA047 C. Diff J910 Pleural effusion, malignantI671 Cerebral aneurysm nonruptured J18X Pneumonia, unspecifed organismI63XXX Cerebral infarct, unspecified precerebral artery J12X Pneumonia, viralI63032 Cerebral infrct, d/t thrombsis left carotid artery L89XXX Pressure ulcers: back, buttock, hip, sacrumK830 Cholangitis L89XXX Pressure ulcers: other sites, stage 4K80XX Cholecystitis, acute with GB stone G8250 Quadriplegia, unspecifiedI50XX Congestive heart failure, acute J9611 Respiratory failure, chronic EXXXXX Diabetic ketoacidosis wo coma A419 Sepsis, unspecified organismI82XXX Embolism & thrombosis, acute E222 SIADHG9340 Encephalopathy T86XX Transplant complicationsK250 Gastric ulcer, acute with hemorrhage K260 Ulcer, duodenal, acute with hemorrhageK2901 Gastritis, acute with bleeding K437 Ventral hernia with gangreneK2931 Gastritis, chronic superficial, with bleeding I472 Ventricular tachycardiaD8981X Graft‐versus‐host disease J129 Viral pneumonia, unspecifiedI5021 Heart failure (congestive) systolic acute Z Codes:K920 Hematemesis Z7682 Awaiting organ transplant statusG919 Hydrocephalus, unspecified Z430 Encounter for attention to tracheostomyD693 Immune thrombocytopenic purpura Z94XX Organ transplant status exc kidney & boneJ849 Interstitial pulmonary disease, unspecified Z95811 Presence of heart assist deviceK5660 Intestinal obstruction Z930 Tracheostomy status

K750 Abscess of liver J9851 MediastinitisI21XX Acute MI K650 PeritonitisN170 Acute tubular necrosis (ATN) J690 Pneumonia, aspirationT8601 Bone marrow transplant rejection J15X Pneumonia, bacterialG935 Brain compression J96XX Respiratory failure, acuteG936 Cerebral edema J121 Respiratory syncytial virus pneumoniaI63031 Cerebral infrc d/t thrombosis right carotid artery A41XX Sepsis, staph, hemophilus, e.Coli, pseudomonasI63XXX Cerebral infarct, most arteries R57X ShockD65 Disseminated intravascular coagulation (DIC) R6511 SIRS of non‐infect origin with ac organ dysfuncJ100X Flu due to oth ident flu virus w f pneumonia I22X Subsequent MIK767 Hepatorenal syndrome K26X Ulcer gastric, acute with perforationK55X Infarct or ischemia, intestine I49XX Ventricular fibrillation / flutterE43 Malnutrition, severe Z9911 Dependence on respirator (vent) status

Diagnoses by Severity Level APRDRG V34 Severity Level 3 Conditions (Moderate)

Severity Level 4 Conditions (Severe)

Secondary Effects of APR‐DRG Assignments - acdis.org · •CMS adopted the DRG system in the...

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