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Medicare Severity Diagnosis-Related Groups

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Presentation on theme: "Medicare Severity Diagnosis-Related Groups"— Presentation transcript:

1 Medicare Severity Diagnosis-Related Groups
Bunnie Cobb, RHIT, CCS EOHIMA - September 22, 2007

2 New DRG System Version 25 Biggest change to DRGs in 24 years
RAND study winner More accurately groups severity of illness (resource intensity) and payment Reduces incentives to specialty hospitals CMS committed to MS-DRGs Similar to changes that began last year, i.e. GI – no cc DRG kept, split cc DRG into 2; w/MCC and w/CC

3 RAND Comparison

4 RAND Comparison continued

5 MS-DRGs Uses CMS DRGs as foundation
Consolidated current DRGs into base DRGs Made no changes to MDCs 14 and 15 (obstetrics and newborns) Eliminated: Low volume DRGs Age-related DRGs Increase in layers (subgroups) As previous, some DRGs are procedure driven. Examples of DRGs removed due to low volume: --primarily due to shift to outpatient 6 Carpal Tunnel Release 56 Rhinoplasty 342, 343 Circumcision Male/female sterilization 43 Pediatric DRGs eliminated <17 years of age CMS declares again that their DRGs were not intended for the non-Medicare population

6 Types of MS-DRGs

7 Examples of DRG Groups MS-DRG MS-DRG Title 009 Bone marrow transplant
009 Bone marrow transplant 131 Cranial/facial procedures w CC/MCC 132 Cranial/facial procedures w/o CC/MCC 175 Pulmonary embolism w MCC 176 Pulmonary embolism w/o MCC 177 Respiratory infections & inflammations w MCC 178 Respiratory infections & inflammations w CC 179 Respiratory infections & inflammations w/o CC/MCC

8 CCs - The bad news Removed >449 codes from the CC list
Some of our most commonly coded conditions, i.e. CHF, COPD, dehydration, atrial fibrillation Penalized for nonspecific diagnoses CHF unspecified = not a CC Chronic diastolic or systolic CHF = CC Acute diastolic or systolic CHF = MCC V24 cases had at least one CC 77.6% of the time, under V25 this will be reduced to 40.34% Table 6I contains the complete CC Exclusions. Table 6I shows the principal diagnoses for which there is a CC exclusion. Each of these principal diagnoses is shown with an asterisk, and the conditions that will not count as a CC, are provided in an indented column immediately following the affected principal diagnosis.

9 CCs - The Good News ? Previous reduction of codes on CCs list in 2006 from 3,326 to 2,583… Now there are 4,922 codes that are either a Major CC or a CC: Major CC 1,580 codes CC 3,342 codes Complications/Comorbidities 􀂃 Reduced CC list from 3,326 to 2,583 diagnoses codes in 2006; now there are 4,922 codes that are either a Major CC or a CC: 􀂃 Major CC 1,580 codes 􀂃 CC 3,342 codes 􀂃 Patients under V 24 had at least one CC 77.6% of the time, under the proposed MS-DRG system, this will be reduced to 40.34%.

10 Only a CC if Patient Discharged Alive
427.41, Ventricular fibrillation 427.5, Cardiac arrest 785.51, Cardiogenic shock 785.59, Other shock without mention of trauma 799.1, Respiratory arrest CMS – patients who are DC’d alive after one of these conditions use resources consistent with an MCC. Patients who expire “could legitimately have one of these diagnoses” so the fact that someone expires is not going to drive the MCC.

11 Financial Impact $ $ $ CMS increased IPPS sum by 3.3%
OR ??? CMS increased IPPS sum by 3.3% Reduction of RWs by 4.8% over 3 years to account for expected coding improvements 1.2% FY08 1.8% FY09 1.8% FY10 See impact file….no one showing a loss In addition, CMS is phasing in the transition of RW based on costs. By 2009 RW will be 100% based on costs, not charges 10/1/06 1/3 costs, 2/3 charges 10/1/07 2/3 costs, 1/3 charges 10/1/08 100% cost based RWs

12 What to Expect Extreme scrutiny of Case Mix More physician queries
+ Delays in billing = More pressure on coders

13 How to Prepare Learn the new rules Make the CC/MCC list your friend
Review all query forms Plan when to query Educate yourself clinically Work with clinicians for more specific documentation

14 References AHIMA’s CoP for Inpatient Coding @
CMS website for IPPS CMS Adopts DRG Overhaul in IPPS Final Rule, 8/10/07 Journal of AHIMA: Severity-Adjusted DRGs for FY 2008? July 2007 Positioning Your Facility for Severity Adjusted Coding, April 2007 New codes in PDF:

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