Presentation on theme: "Medicare Severity Diagnosis-Related Groups"— Presentation transcript:
1 Medicare Severity Diagnosis-Related Groups Bunnie Cobb, RHIT, CCSEOHIMA - September 22, 2007
2 New DRG System Version 25 Biggest change to DRGs in 24 years RAND study winnerMore accurately groups severity of illness (resource intensity) and paymentReduces incentives to specialty hospitalsCMS committed to MS-DRGsSimilar to changes that began last year, i.e. GI – no cc DRG kept, split cc DRG into 2; w/MCC and w/CC
5 MS-DRGs Uses CMS DRGs as foundation Consolidated current DRGs into base DRGsMade no changes to MDCs 14 and 15 (obstetrics and newborns)Eliminated:Low volume DRGsAge-related DRGsIncrease in layers (subgroups)As previous, some DRGs are procedure driven.Examples of DRGs removed due to low volume:--primarily due to shift to outpatient6 Carpal Tunnel Release56 Rhinoplasty342, 343 CircumcisionMale/female sterilization43 Pediatric DRGs eliminated <17 years of ageCMS declares again that their DRGs were not intended for the non-Medicare population
7 Examples of DRG Groups MS-DRG MS-DRG Title 009 Bone marrow transplant 009Bone marrow transplant131Cranial/facial procedures w CC/MCC132Cranial/facial procedures w/o CC/MCC175Pulmonary embolism w MCC176Pulmonary embolism w/o MCC177Respiratory infections & inflammations w MCC178Respiratory infections & inflammations w CC179Respiratory 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 fibrillationPenalized for nonspecific diagnosesCHF unspecified = not a CCChronic diastolic or systolic CHF = CCAcute diastolic or systolic CHF = MCCV24 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 codesCC 3,342 codesComplications/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, underthe proposed MS-DRG system, this will be reduced to 40.34%.
10 Only a CC if Patient Discharged Alive 427.41, Ventricular fibrillation427.5, Cardiac arrest785.51, Cardiogenic shock785.59, Other shock without mention of trauma799.1, Respiratory arrestCMS – 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 improvements1.2% FY081.8% FY091.8% FY10See impact file….no one showing a lossIn addition, CMS is phasing in the transition of RW based on costs.By 2009 RW will be 100% based on costs, not charges10/1/06 1/3 costs, 2/3 charges10/1/07 2/3 costs, 1/3 charges10/1/08 100% 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 formsPlan when to queryEducate yourself clinicallyWork with clinicians for more specific documentation
14 References AHIMA’s CoP for Inpatient Coding @ ahima.org CMS website for IPPSCMS Adopts DRG Overhaul in IPPS Final Rule, 8/10/07Journal of AHIMA:Severity-Adjusted DRGs for FY 2008? July 2007Positioning Your Facility for Severity Adjusted Coding, April 2007New codes in PDF: