1. 2008 Medicare Changes Presented by: Kyra Brown, RHIA, CCS
Program Manager for Documentation and Coding Outcomes
Outcomes Management Department
Methodist Medical Center

2. DRG Changes 2007 - 579 CMS DRGs 2008 - 745 MS-DRGs
Medicare Severity DRGs
FY 2008 a .6% decrease in the relative weight of all cases will occur because of predicted increases due to better documentation.
FY 2009 & % adjustment will occur, to account for better Documentation & Coding.

3. A Significant Decrease in the List of Diagnoses that are Considered to be a CC Occurred on 10/1/07
,326 Codes were on the CC list.
77.6% of Patients have a CC.
2008 – 2,583 are on the CC List.
40.34% of Patients will have a CC.

4. A Substantial CC is a Secondary Diagnosis that Increases Reimbursement
Originally a substantial CC was defined as a condition which, because of its presence with a specific principal diagnosis would cause an increase in the length of stay by at least one day in at least 75% of the patients.
In the Federal Register Proposed Changes for FY 2008 CMS Stated that they reviewed the CC list to reexamination the secondary diagnoses that qualify as a cc.
Their intent was to better distinguish cases that are likely to result in increased hospital resource use.
Using a combination of mathematical data and the judgment of CMS medical officers, they included that condition on the CC list if it could demonstrate that its presence would lead to substantially increased hospital resource use.

5. Diabetes Diagnoses that are no longer a CC:
DM, Type 1
DM, Type 2, Uncontrolled
DM, with Renal Manifestations
Diabetes with Neurological Manifestations
Diagnoses that will be Major CC’s:
Diabetic Ketoacidosis
Diabetes with Hyperosmolarity
Diagnoses that will be a CC:
Diabetes Insipidus

6. Disorders of Fluid, Electrolyte and Acid Base Balance
Diagnoses that are no longer a CC:
Volume Depletion
Dehydration
Hypovolemia
Fluid Overload
Hyperpotassemia
Diagnoses that will be Major CC’s:
No Diagnoses
Diagnoses that will be a CC:
Hyperosmolality and/or Hypernatremia
Hyposmolality and/or Hyponatremia
Acidosis
Alkalosis
Mixed acid-base balance disorder

7. Example: Colon CA with Resection
Major Small & Large Bowel Procedures
DRG W/O CC or MCC $
DRG with CC (Add hypernatremia or hyponatremia)
$15,868.53
DRG with Major CC $23,493.99

8. Anemia Diagnoses that are no longer a CC:
Blood loss anemia
Chronic blood loss, anemia
Chronic Iron Deficiency Anemia due to Blood loss
Protein-Deficiency Anemia
Sideroblastic Anemia
Anemia Associated with other Nutritional Deficiencies
Diagnoses that will be Major CC’s:
Aplastic Anemia due to: Chronic Systemic Disease, Drugs, Infection, Radiation
Red Cell Aplasia
Diagnoses that will be a CC:
Acute Blood Loss Anemia
Acute Blood Loss Anemia, following Surgery
Hemolytic Anemia
Constitutional Red Blood Cell Aplasia
Other Constitutional Aplastic Anemia
Aplastic Anemia, Unspecified

9. Example: Nonunion Fracture Removal of Hardware with Revision of ORIF
Lower Ext & Humerus Procedure Except Hip, Foot, Femur
DRG Without CC/MCC $
DRG With CC (Add Acute BL Anemia) $
DRG With Major CC $11,686.25

10. Cardiac Diagnoses. Diagnoses with
Cardiac Diagnoses **Diagnoses with ** are not counted if the Patient expires
Diagnoses that are no
longer a CC:
CHF, Heart Failure, Unspecified
Angina Pectoris
Atrial Fibrillation
Mitral Valve Diseases
Aortic Valve Diseases
Trifascicular Block
Other Second Degree AV Block
Other Bilateral Bundle Branch Block
Status Heart Valve Transplant (Porcine Valve)
Diagnoses that will be Major CC’s:
Ventricular Fibrillation**
Ventricular Flutter
Cardiac Arrest**
Heart Failure, Acute or Acute on Chronic Systolic or Diastolic
Cardiogenic Shock**
Diagnoses that will be a CC:
Unstable Angina
Paroxysmal SVT, Paroxysmal VT
Atrial Flutter
Heart failure, Left, Chronic or Unspecified Systolic or Diastolic

11. Example: Mitral Insufficiency, CAD, Mitral Valve Annuloplasty, CABG x5
Cardiac Valve & Other Major Cardiothoracic Procedure
DRG Without Cath,Without CC/MCC
$27,354.47
DRG With CC (Chronic Systolic/Diastolic Heart Failure)
$29,865.03
DRG 219 – With MCC (Acute on Chronic Systolic/Diastolic HF)
$ 37,578.70

12. Respiratory Diagnoses. Diagnoses with
Respiratory Diagnoses **Diagnoses with ** are not counted if the Patient expires
Diagnoses that are no
longer a CC:
COPD, Emphysema
Chronic Bronchitis
Interstitial Emphysema
Postinflammatory Fibrosis
Hypoxemia, Apnea
Diagnoses that will be a CC:
COPD, with Acute Exacerbation
COB, with Acute Exacerbation
Asthma, with Acute Exacerbation
Pleural Effusion
Atelectasis
Chronic Respiratory Failure
Aphasia
Cheyne-Stokes Respirations
Hemoptysis
Diagnoses that will be
Major CC’s:
Pneumonia
Empyema
Acute Respiratory Failure
Acute on Chronic RF
Respiratory Arrest**

13. Example: CHF With Systolic Dysfunction
Heart Failure & Shock
DRG Without CC/MCC $
DRG 292 – With CC (Added COPD Exacerbation) $
DRG 291 – With Major CC $

14. Urinary Tract Diagnoses
Diagnoses that are no longer a CC:
Urinary Retention
Urinary Obstruction
Bladder Neck Obstruction
Hematuria
Cystitis
Postoperative Urethral Stricture
Diagnoses that will be Major CC’s:
Acute Renal Failure
ATN
End Stage Renal Disease
Diagnoses that will be a CC:
UTI
Acute Cystitis
Chronic Kidney Disease, Stage IV, CKD, Stage V
(CKD Staging posted in dictation areas and sent to all Physician Offices Via )
Hydronephrosis

15. Miscellaneous Diagnoses
Diagnoses that are no longer a CC:
Multiple Sclerosis
Alcoholic Cirrhosis
Biliary Cirrhosis
Systemic Lupus Erythematosus
Felty’s Syndrome
Stress Fractures
Carbuncle & Furuncle
Impetigo
Post-Laminectomy Syndrome
Diagnoses that will be Major CC’s:
Encephalopathy
Quadriplegia
Decubitus Ulcer (most sites)
Shock, cardiogenic or septic
Kwashiorkor, Nutritional Marasmus
DIC
Diagnoses that will be a CC:
Anoxic Brain Damage
Paraplegia, Hemiplegia
Candidiasis of the Mouth
Hematemesis
Blood in Stool
Cachexia, Malnutrition

16. Example: Appendicitis, Appendectomy
Pt also had: Morbid Obesity, HTN, GERD, Asthma, Hypothyroidism, Hypokalemia
DRG Without a CC $
DRG 343 – With a CC $
Added BMI code V85.4, BMI 40 and Over; Based on Dietician’s Documentation as Specified in Coding Rules. (BMI <19 also a CC).

17. Effective October 1, ALL codes must be Identified as Present on Admission (POA) or Not. POA: Reporting Guidelines
Medical Record Documentation from Any Provider Involved in the Care and Treatment of the Patient May Be Used to Support the Determination of Whether a Condition Was POA or Not.
In the Context of the Official Coding Guidelines, the Term “Provider” Means a Physician or Any Qualified Healthcare Practitioner Who is Legally Accountable for Establishing the Patient’s Diagnosis. (PA, NP)
Diagnoses Subsequently Confirmed After Admission Are Considered POA If, At the Time of Admission They Are Documented as Suspected, Possible, Rule Out, Differential Diagnosis, or Constitute an Underlying Cause of a Symptom
That Is Present At the Time of Admission.

18. Serious Preventable Events:
Effective October 1, 2008 the Following Conditions will No Longer Count as a CC, Unless they are Identified as Present On Admission.
Serious Preventable Events:
Object Left in Surgery
Air Embolism
Blood Incompatibility
Catheter Associated Urinary Tract Infections
Pressure/Decubitus Ulcers
Vascular Catheter – Associated Infection
Mediastinitis After CABG Surgery
Hospital Acquired Injuries – Fractures, Dislocations, Intracranial Injury, Crushing Injury, Burn, and Other

19. The Following Conditions Are Also Under Consideration for FY 2009
Ventilator Associated Pneumonia
Staphylococcus Aureus Septicemia
Deep Vein Thrombosis
Pulmonary Embolism

20. Summary (See Documentation Tips Sheet)
Document all diagnoses that are POA, All Diagnoses that Will be Treated or Monitored, etc.
Document: Acute, Chronic and Exacerbated
Do Not Document: Renal Insufficiency, CHF, Postoperative Anemia, Surgical Anemia