1. Most Responsible Diagnosis & Complexity Coding
HS317B – Coding & Classification of Health Data
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2. Background on Standards
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Background on Standards
In 1995 at a First Ministers meeting, the federal, provincial & territorial governments agreed that Canada would adopt a unified system for the collection of health care data.
Discharge Abstract Database (DAD
National Ambulatory Care Reporting System (NACRS)
In 2001 ICD-10 was introduced to Canada in a staggered approach.
Canadian Coding Standards for ICD-10-CA enhance the World Health Organization’s rules & guidelines.
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3. The idea: to create a database of health information that is relevant
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The idea: to create a database of health information that is relevant
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4. Health Information Database
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Health Information Database
At a local level to demonstrate:
quality improvement, program planning, benchmarking, research, strategic planning, utilization management, risk management, case costing & funding
Provincially:
case costing, funding, rationalization of services, population health, system evaluation & planning
Nationally:
evaluation of outcomes, grouping of data, healthcare planning, manpower planning, monitoring trends, morbidity and mortality reporting, patient safety
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5. Most Responsible Diagnosis Diagnosis Typing Interventions
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Most Responsible Diagnosis
Diagnosis Typing
Interventions
Data Elements (demographics, etc)
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6. Process for Classification
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Process for Classification
Identify Most Responsible Diagnosis
Based on MRDx coded cases are slotted into one of 25 major clinical categories (MCC).
Cases are grouped to similar conditions together into Case Mix Groups
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7. Medical/Surgical CMG Methodology
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Medical/Surgical CMG Methodology No
Valid MRDx?
CMG 999
Yes
Yes
Age < 29
MCC 15
Days No
The grouper uses only selected information from the patient’s abstract, including age, gender, birth weight, medical diagnoses, interventions and whether the patient was a typical or an atypical visit (to be discussed later). Medical diagnoses and procedures are determined from the ICD-9/CCP, the ICD9-CM, or the ICD-10-CA/CCI classification systems.
From the patient’s abstract, the Most Responsible Diagnosis (MRDx) 'the one diagnosis that describes the most significant condition of a patient that causes his/her stay in hospital' is used to assign the patient to one of the 25 MCC. This may not always be the condition for which the patient was initially admitted.
Within each MCC, the presence or absence of an operative procedure will direct the patient towards a surgical or medical partition. In the surgical partition, the grouper loops through all procedures recorded on the patient’s abstract to find one that is in the same MCC as the MRDx. If more than one procedure is found that belongs in this MCC the case is assigned to the CMG highest on the hierarchy. The surgical hierarchy is a decision rule that orders procedures from most to least resource intensive. The hierarchy is defined by clinical judgement and expected resource consumption.
If the only procedures that are recorded are not listed within the MCC of the MRDx, the case will be assigned to a CMG that is associated with Unrelated Operating Room Procedures (CMG ). If there are no procedures reported on the patient’s abstract, the patient will be assigned to the medical partition of the MCC which groups patients on the basis of clinical diagnoses.
Yes
Yes
Yes
Assign MCC Based
O.R.
on Most responsible
Procedure In MCC
Surgical Partition
Procedure
Diagnosis No No
Unrelated O.R.
Medical Partition
Procedure
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8. MCC into Case Mix Groups
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MCC into Case Mix Groups
Grouping similar types of patients and or resources together into CMGs
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9. Most Responsible Diagnosis
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Most Responsible Diagnosis
It is the one diagnosis or condition that can be described as being most responsible for the patient’s stay in hospital
If there is more than one such condition, the one held most responsible for the greatest portion of the LOS or greatest use of resources should be selected
If no diagnosis was made, the main symptom, abnormal finding or problem should be selected as MRDx
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10. 30/11/2018
Patient was playing hockey at an arena when he was struck by another player’s stick, falling on his right arm. He sustained a 5 cm laceration on his head. He also experienced pain in his right arm. In hospital he had a CT scan of his head which was normal. X-ray of his right arm revealed a fracture of the ulnar shaft.
He was taken to the OR for fixation of the radius with a plate. The laceration was also sutured.
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11. Which condition would be the MRDx?
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Which condition would be the MRDx?
Laceration of the scalp
Fracture of the radius
Why?
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12. 30/11/2018
Patient presents to hospital with acute chest pain. After being admitted to hospital for observation and diagnostic testing (heart catheterization and ECG) no definite cause could be found. The chest pain gradually resolved and the patient was discharged.
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13. 30/11/2018
What is the MRDx?
If no definite diagnosis is made, the main symptom, abnormal finding or problem should be selected as MRDx.
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14. Choosing between two or more diagnosis of equal importance
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Choosing between two or more diagnosis of equal importance
Acute Gastritis
Acute Duodenitis
Acute Bronchitis
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15. Diagnosis of equal importance
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Diagnosis of equal importance
When two or more diagnosis of equal importance are listed
No clear indication as to which one is MRDx
Select the condition for which a definitive (as opposed to diagnostic) surgical or non-surgical procedure has been performed
If no surgery performed select the first-listed diagnosis as the MRDx
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16. Specificity Peptic Ulcer Disease Chronic Bleeding Duodenal Ulcer
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Specificity
Peptic Ulcer Disease
Chronic Bleeding Duodenal Ulcer
Cerebrovascular Accident
Cerebral hemorrhage
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Specificity
When the “main” diagnosis describes a condition in general terms
Select a more precise code about site or nature if there are more descriptive terms reported among the “other” diagnosis
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18. Using Diagnostic Test Results
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Using Diagnostic Test Results
Patient was admitted for skin lesion. Pathology report showed squamous cell carcinoma
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19. Using Diagnostic Test Results
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Using Diagnostic Test Results
Use
Laboratory,
X-ray,
Pathology,
Other diagnostic results
When they clearly add specificity to diagnosis/conditions documented din physician’s note
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20. Inappropriate application of Diagnostic Tests
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Inappropriate application of Diagnostic Tests
Microbiology report positive for micro-organism growth
No documentation in physician’s notes identifying diagnosis or treatment for urinary tract infection
CT scan reveals adhesions of the abdomen
No documentation in physician’s notes identifying it as the cause of abdominal pain
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21. Acute on Chronic Condition
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Acute on Chronic Condition
Acute on chronic cholecystitis
Acute exacerbation of chronic obstructive pulmonary disease
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22. Acute on Chronic conditions
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Acute on Chronic conditions
Where MRDx is both acute/subacute & chronic
If there is no combination code for acute on chronic then acute condition should be coded first
The chronic condition is a diagnosis type 3
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23. Impending or Threatened Condition
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Impending or Threatened Condition
Threatened abortion
Stage 4 decubitus ulcer. Documentation by physician states impending gangrene
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24. Impending or threatened condition
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Impending or threatened condition
If a threatened or impending condition
Is documented
Did not occur during the episode of care
Check the lookup for terminology such as “impending or threatened” under the main term
If such as index exists assign appropriate code
If it doesn’t exist than the condition described as impending or threatened should not be coded
Code to the precursor condition
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25. Suspected condition/ Query diagnosis
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Suspected condition/ Query diagnosis
Chest pain, Query Myocardial Infarction
Query Multiple Sclerosis
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26. Suspected condition/Query Diagnosis
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Suspected condition/Query Diagnosis
If no definite diagnosis has been established by the end of an episode of health care
Code the information that permits
The greatest degree of specificity and knowledge
The condition that necessitated care of investigation
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If, after an episode of health care, the MRDx is still recorded by the physician as “suspected”, “questionable”, etc and there is no further information or clarification
Code the suspected diagnosis as if it were established
Use the prefix “Q” in these circumstances whenever available.
If the condition has been ruled out after investigation use Z03.~ Medical observation and evaluation for suspected diseases & conditions
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28. (Q)I21.9(3) Query Myocardial Infarction
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R07.4 (M) Chest pain
(Q)I21.9(3) Query Myocardial Infarction
(Q) Query Multiple Sclerosis (M)
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Sequelae
Late effect of cerebrovascular accident now hospitalized for treatment of dysphagia
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Sequelae
Conditions that are no longer present as the cause of a current problem undergoing treatment or investigation
Code the presenting condition as MRDx
Code the sequelae of the underlying condition with a diagnosis type 3
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31. Admissions from Emergency Room
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Admissions from Emergency Room
Diagnosis of each abstract (emergency & inpatient record)
Must accurately reflect the circumstances for or treatment provided during that episode of care
If treatment started in ER and patient was admitted
The identified condition must be recorded as MRDx
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32. If no definite treatment for injury or condition occurs in the ER
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If no definite treatment for injury or condition occurs in the ER
And no reason is given for why the patient was admitted
Assume that it was for continuation of treatment of presenting condition
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33. Summary of MRDx Rules Diagnosis of Equal Importance Specificity
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Summary of MRDx Rules
Diagnosis of Equal Importance
Specificity
Using Diagnostic Test Results in Coding
Acute and Chronic Conditions
Impending or Threatened Conditions
Underlying Symptoms Or Conditions
Suspected Conditions/Query Diagnosis
Sequelae
Admissions from Emergency Department
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CMG/MCC Assignment
Complexity Levels
RIW
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35. Diagnosis Typing – a 1 digit code
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Diagnosis Typing – a 1 digit code
To indicate the relationship of the diagnosis to the patient’s stay in hospital
Required for every ICD-10-CA code recorded on the Discharge Abstract Database (DAD) (inpatients)
To differentiate conditions that influence the patient’s stay from those that do not
To flag post-admission comorbidities
To use in complexity assignment for CMG
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