際際滷

際際滷Share a Scribd company logo

Lecture Icd 10

Ray Arons
Ray Arons

This document provides an overview of medical record coding and diagnosis-related groups (DRGs) for a lecture on the hospital revenue cycle. It discusses international classification of diseases coding methods, including ICD-9-CM coding history and examples of disease and procedure codes. It also covers obstacles to payment in the revenue cycle such as incomplete bills and coding errors.

1 of 30
Downloaded 32 times
Baruch College/Mount Sinai School of Medicine Program in Health Care Administration and Policy Medical Record Coding and DRGs BUS9100 Lecture 10 Raymond R. Arons, Dr. P.H, M.P.H February 9, 2010
Lecture 10 2 Baruch College/Mount Sinai School of Medicine Program In Health Care Administration and Policy BUS 9100: The Social and Governmental Environment of the Business of Health Care Lecture 10-February 9, 2010 Revenues, Medical Record Coding and DRGs Raymond R. Arons, Dr. P.H, M.P.H http://www.cms.hhs.gov/TheChartSeries/03_Health_Care_Facts_Figures.asp#TopOfPage Section 10.0 The Hospital Revenue Cycle Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 3 INPATIENT REVENUE CYCLE Patient Demographics Admitted Insurance, Other To Hospital Data Captured Diagnoses (Dx.), Patient Procedures (Pr.), Discharged in Medical Record Coders take the Dx. Bill is submitted and Pr. Convert to to Insurance ICD codes for billing Company For Payment $$$ 3 Revenue Cycle Obstacles to Payment Bill is not complete and is bounced by Insurance Company Insurance ID incorrect. Other, missing elements such as secondary payer, age sex, race, ethnicity, procedure dates etc. Submission is not within the time limits. Other factors such as denials etc, Admitted within 30 days of discharge. Never received claim. Errors in medical record coding. 4 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 4 Section 10.1 International Classification of Diseases Coding Methods Coding Methods Currently in Use International Classification of Diseases - ICD-9-CM Coding of Inpatient Discharges International Classification of Diseases - ICD-10-CM Mandated for 2013 but used as of 12/30/09 Diagnosis-related Groupings (DRGs) Hospital reimbursement -Medicare Hospital reimbursement -Non Medicare Physician Current Procedure Terminology (CPT) Physicians for procedures performed Common Procedure Coding System (HCPCS) Used by vendors of equipment and services 6 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 5 International Classification of Diseases (ICD-9-CM) History Definitions Classification of Diseases Groupings Disease Coding Procedure Grouping Procedure Coding Other Areas such as V codes, E codes 7 ICD History Statistical classification of diseases date back to the eighteenth century with a primary focus upon the causes of death The Sixth Revision, in 1948 expanded to include non- fatal diseases. In 1950 the US Public Health Service and the Veterans Administration began independent tests of ICD-6 for hospital indexing purposes. In 1951 the Presbyterian Hospital in New York City adopted the ICD-6th Revision with some modifications for use in its record department (HCFA,1980) 8 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 6 ICD History The Ninth revision in 1975 in Geneva included procedures in medicine and of impairments, and handicaps. ICD-9-CM became effective in January 1979 and is currently up to its latest revision to keep up with new technologies, procedures, and diseases. Over the past century, ICD was under the control of WHO, The Commission on Professional Hospital Activity and currently the Health Care Financing Administration (HCFA), and Centers for Medicare and Medicaid (CMS) ICD-10-CM was released in 1999 and will be required for physician and hospital use in 2013 and currently is optional as of December 2009 9 Definitions A classification of disease may be defined as a system of categories to which morbid entities are assigned according to established criteria. A Statistical classification of diseases must encompass the entire range of morbid conditions within a manageable number of categories (ICD-10, WHO,1992) 10 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 7 Examples of I9 Codes Infectious and Parasitic Diseases (000-139) 042 Human immunodeficiency virus (HIV) 090.0 Early congenital syphilis,symptomatic Neoplasms (140-239) 162.2 Malignant neoplasm of the main bronchus 191.1 Malignant neoplasm of the fontal lobe Endocrine,Nutritional and Metabolic Diseases and Immunity Disorders (240-319) 250.1 Diabetes mellitus with ketoacidosis 278.01 Morbid obesity 11 continued... Examples of I9 Codes Blood and Blood-Forming Organs (280-289) 282.6 Sickle-cell anemia 285.9 Anemia, unspecified Mental Disorders (290-319) 295.4 Acute schizophrenic episode 296.3 Major depressive disorders Nervous System and Sense Organs (320-389) 332.0 Parkinsons disease with paralysis agitans 362.0 Diabetic retinopathy 12 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 8 Examples of I9 Codes Diseases of the Circulatory System (390-459) 410.1 Acute myocardial infarction of anterolateral wall 414.0 Heart Failure Diseases of the Respiratory System (460-519) 492.0 Emphysema bleb 493.9 Asthma, unspecified Diseases of the Digestive System (520-579) 540 Acute appendicitis with generalized peritonitis 550 Inguinal hernia, with gangrene 13 continued... Examples of I9 Codes Diseases of the Genitournary System (580-629) 592.0 Calculus of the kidney 600 Hyperplasia of prostate Complications of Pregnancy and Childbirth and the Puerperium (630-676) 633 Ectopic pregnancy 634 Spontaneous abortion Diseases of the Skin and Subcutaneous Tissue(680- 709) 684 Impetigo 697.0 Lichen planus 14 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 9 Examples of I9 Codes Congenital Anomalies (740-759) 734.61 Flat foot congenital 749.00 Clef palate, unspecified Certain Conditions Originating in the Perinatal Period (760-779) 760.0 Maternal hypertensive disorder 762.4 Prolapsed cord Symptoms, Signs and Ill-defined Conditions (780-799) 780.6 Fever 780.1 Hallucinations 15 continued... Examples of I9 Codes Diseases of the Musculoskeletal System and Connective Tissue (710-739) 714.0 Rheumatoid arthritis 722 Intervertebral disc disorder 733.1 Pathologic fracture Injury and Poisoning (800-999) 800.1 Open fracture of clavicle 952.01 C1/C4 level with complete lesion of spinal cord 16 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 10 Examples of I9 Codes Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V01- V82) V30.00 Single live born vaginal delivery in hospital V60.3 Person living alone Supplementary Classification of External Causes of Injury and Poisoning (E800-E999) E813 Motor Vehicle traffic accident highway collision E800 Railway accident involving collision with train 17 continued... Examples of I9 Procedure Codes Operations of the Nervous System (01-05) 01.0 Cranial puncture 01.2 Craniotomy and craniectomy 03.01 Removal of foreign body from spinal canal Operations on the Endocrine System (06-07) 06.01 Aspiration of thyroid 07.8 Thymectomy Operations on the Eye (08-16) 16.3 Evisceration of eyeball 16.82 Repair of wound of orbit 18 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 11 I9 Procedure Codes Operations of the Ear (18-20) 18.0 Incision of External Ear 20.0 Myringotomy 20.96 Implantation or replacement of cochlear prosthetic device Operations on the Nose,Mouth and Pharynx (21-29) 21.0 Control of epistaxis 21.7 Reduction of a Nasal Fracture Operations on the Respiratory System (30-34) 32.4 Lobectomy of lung 33.5 Lung transplant 19 continued... I9 Procedure Codes Operations on the Cardiovascular System (35-39) 35.2 Replacement of Heart Valve 37.5 Heart Transplant 38.5 Ligation and stripping of varicose veins Operations on the Hemic and Lymphatic System (40-41) 40.11 Biopsy of lymphatic structure 41.01 Autologous bone marrow transplant Operations on the Digestive System (42-54) 42.42 Total esophagectomy 47.0 Appendectomy 20 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 12 I9 Procedure Codes Operations on the Urinary System (55-59) 55.5 Complete nephrectomy 55.6 Kidney Transplant Operations on Male Genital Organs (60-64) 60.2 Transurethral prostatectomy 64.5 Operation for sex transformation, NEC Operations on Female Genital Organs (65-71) 68.6 Radical abdominal hysterectomy 69.92 Artificial insemination 21 continued... I9 Procedure Codes Obstetrical Procedures (72-75) 74.0 Classical cesarean section 72.31 High forceps operation with episiotomy Operations on Musculoskeletal System (76-84) 79.85 Open reduction of dislocation of hip 81.51 Total hip replacement Operations on the Integumentary System(85-86) 85.23 Subtotal mastectomy 85.94 Removal of implant of breast 22 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 13 I9 Procedure Codes Miscellaneous Diagnostic and Therapeutic Procedures (87-99) 87.1 Other x-ray of face, head and neck 88.4 Arteriography using contract materials 88.93 Magnetic resonance imaging of spinal canal 89.4 Cardiac stress tests and pacemaker checks 94.4 Psychotherapy and counseling 99.92 Other acupuncture 23 continued... Usage of I9 Coding Systems All discharges from hospitals, visits to physician offices, ambulatory care centers, and other sites of the delivery of care require and ICD-9-CM code that reflects the various diseases that were treated and procedures performed. All bills to third party agencies, Medicare, Medicaid, Blue Cross and other payors require diseases and procedures that were written in charts to be coded by staff prior to being submitted for payment. As of 2013 the ICD-10-CM will be required. 24 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 14 A Sample of ECODES (Accidents) E8000 RR COLLISION NOS-EMPLOY E8001 RR COLL NOS-PASSENGER E8002 RR COLL NOS-PEDESTRIAN E8003 RR COLL NOS-PED CYCLIST E8008 RR COLL NOS-PERSON NEC E8009 RR COLL NOS-PERSON NOS E8010 RR COLL W OTH OBJ-EMPLOY E8011 RR COLL W OTH OBJ-PASNGR E8012 RR COLL W OTH OBJ-PEDEST E8013 RR COLL W OTH OBJ-CYCL E8018 RR COL W OTH OBJ-PER NEC E8019 RR COL W OTH OBJ-PER NOS 25 A Sample of VCODES V3000 SINGLE LB IN-HOSP W/O CS V3001 SINGLE LB IN-HOSP W CS V301 SINGL LIVEBRN-BEFORE ADM V302 SINGLE LIVEBORN-NONHOSP V3100 TWIN-MATE LB-HOSP W/O CS V3101 TWIN-MATE LB-IN HOS W CS V311 TWIN, MATE LB-BEFORE ADM V312 TWIN, MATE LB-NONHOSP V3200 TWIN-MATE SB-HOSP W/O CS V3201 TWIN-MATE SB-HOSP W CS V321 TWIN, MATE SB-BEFORE ADM V322 TWIN, MATE SB-NONHOSP 26 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 15 A Sample of Burn I9 Codes 94510 1ST DEG BURN LEG NOS 94511 1ST DEG BURN TOE 94512 1ST DEG BURN FOOT 94513 1ST DEG BURN ANKLE 94514 1ST DEG BURN LOWER LEG 94515 1ST DEG BURN KNEE 94516 1ST DEG BURN THIGH 94519 1ST DEG BURN LEG-MULT 94520 2ND DEG BURN LEG NOS 94521 2ND DEG BURN TOE 94522 2ND DEG BURN FOOT 94523 2ND DEG BURN ANKLE 27 Sample of Poisoning I9 Codes 96502 POISONING-METHADONE 96509 POISONING-OPIATES NEC 9651 POISONING-SALICYLATES 9654 POIS-AROM ANALGESICS NEC 9655 POISONING-PYRAZOLE DERIV 96561 POIS-PROPIONIC ACID DERV 96569 POISON-ANTIRHEUMATIC NEC 9657 POIS-NO-NARC ANALGES NEC 9658 POIS-ANALGES/ANTIPYR NEC 9659 POIS-ANALGES/ANTIPYR NOS 9660 POISON-OXAZOLIDINE DERIV 28 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 16 Example of I9 Cardiac Surgical Procedures 3610 AORTOCORONARY BYPASS NOS 3611 AORTOCOR BYPAS-1 COR ART 3612 AORTOCOR BYPAS-2 COR ART 3613 AORTOCOR BYPAS-3 COR ART 3614 AORTCOR BYPAS-4+ COR ART 3615 1 INT MAM-COR ART BYPASS 3616 2 INT MAM-COR ART BYPASS 3617 ABD-CORON ARTERY BYPASS 3619 HRT REVAS BYPS ANAS NEC 362 ARTERIAL IMPLANT REVASC 3631 OPEN CHEST TRANS REVASC 29 Example I9 Neurosurgery Procedures 0102 VENTRICL SHUNT TUBE PUNC 0109 CRANIAL PUNCTURE NEC 0111 CLOS CEREB MENINGES BX 0112 OPEN CEREB MENINGES BX 0113 CLOSED BRAIN BIOPSY 0114 OPEN BRAIN BIOPSY 0115 SKULL BIOPSY 0118 OTHER BRAIN DX PROCEDURE 0119 OTHER SKULL DX PROCEDURE 0121 CRANIAL SINUS I & D 0122 REMOV INTRACRAN STIMULAT 0123 REOPEN CRANIOTOMY SITE 30 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 17 Example I9 Orthopedic Procedures 7971 CL REDUC DISLOC-SHOULDER 7972 CL REDUC DISLOC-ELBOW 7973 CL REDUC DISLOC-WRIST 7974 CL REDUC DISLOC-HAND/FNG 7975 CL REDUC DISLOC-HIP 7976 CL REDUC DISLOC-KNEE 7977 CL REDUC DISLOC-ANKLE 7978 CL REDUC DISLOC-FOOT/TOE 7979 CL REDUC DISLOCATION NEC 7980 OPEN REDUC-DISLOCAT NOS 7981 OPN REDUC DISLOC-SHOULDR 7982 OPEN REDUC-ELBOW DISLOC 31 Example of I9 Obstetrical Procedures 734 MEDICAL INDUCTION LABOR 7351 MANUAL ROTAT FETAL HEAD 7359 MANUAL ASSIST DELIV NEC 736 EPISIOTOMY 738 FETAL OPS-FACILITATE DEL 7391 EXT VERSION-ASSIST DELIV 7392 REPLACE PROLAPSED CORD 7393 INCIS CX TO ASSIST DELIV 7394 PUBIOTOMY TO ASSIST DEL 7399 OPS ASSISTING DELIV NEC 740 CLASSICAL C-SECTION 741 LOW CERVICAL C-SECTION 32 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 18 Section 9.2 Diagnostic-Related Groupings (DRGs) System The Diagnosis-related Grouping System (DRGs) Introduction Design History Grouping Systems Major Diagnosis Categories Example DRGs Diagnosis-related grouping construct 34 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 19 Introduction Medicare and Medicaid were adopted in 1965. Since their adoption and for the past 45 years the expenses for these federal funded programs have been uncontrollable. Many methods were attempted to reduce their annual growth. The most radical occurred in 1980 with the passage of public law PL-98-21 known as the Prospective Payment System (PPS). It mandated that hospitals rates were to be announces the prior year before they went into effect and rather than pay by a patients length of stay, payment would be by the diagnoses treated. 35 What Presidential Administration? DRG Design A system developed at Yale known as the diagnosis-related grouping system (DRG) was used as it currently is today, 29 years later. The patient variables to be used in the construction of the Diagnosis-related grouping system would consist of the information routinely collected by hospital in its current data collection and abstraction systems. These included diagnosis and procedure codes, death, age, and the existence of complications and comorbidities (CC). The system had as its goal the creation of a manageable number of DRGs to which payments would be assigned. Using the ICD-9- CM coding system was ruled out due to it having thousands of diagnoses and procedures. 36 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 20 DRG History 1978 - HCFA funded an experiment with eighteen New Jersey hospitals having 383 DRGs as a prospective payment system. The ICD-8 coding system was used to construct the DRGs. 1979 - The ICD-9-CM based DRGs were funded for development at Yale School of Organization and Management. 1980 - Publication of the methodology used to construct the DRGs at Yale: Fetter R, Shin Y, Freeman RF, Averill R, Thomson JD.(1980) Case mix definitions by diagnosis-related groupings Medical Care, 18 (2, Supplement pp1-53). 37 continued... DRG History 1982 - All New Jersey hospitals used the DRGs for all discharges including Medicare, Medicaid and all private payors using a DRG system with 430 categories. 1983 In 1980 public law PL-98-21 was passed known as the Prospective Payment System (PPS). 2010 The DRGs are into their 28th version and are used for all Medicare discharges and applied as a classification system for all discharge abstracts.. 38 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 21 DRG History DRGs have been exported to France and a number of the European 8 nations. The DRG system is designed by a division of 3M which has been involved in its design since its inception. New York State uses a Non-Medicare Grouper for its younger patients. It has more categories such as: The DRG 500 Series (Major Complications) The DRG 600 Series (Neonates) The DRG 700 Series (HIV) The DRG 800 Series (TB) 39 Grouping Systems A grouper is a statistical program that takes the billing claims submitted to Medicare and places them into similar clinical and resource intense groupings. Each group is assigned a relative weight based on the mean charges submitted yearly. The results are reweighing the diagnosis-related groupings (DRGs) and the basis for rates of reimbursement for following year. In addition new DRGs are created based upon the use of new technologies that are considered standards of practice. . 40 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 22 Grouping Systems Therefore in September of each year CMS will produce a list of new adopted Medicare DRGs with estimated payments for the upcoming fiscal year The DRGs are divided into surgical or medical treatments The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. The principal procedure performed for definitive treatment rather than diagnostic or exploratory purposes, or that was necessary to treat a complication. The principal procedure is usually related to the principal diagnosis. 41 continued... Grouping Systems Complication or comorbidity (CC) are defined as: A complication is a condition that arises during the hospital stay that prolongs the length of stay one- day in approximately 75 percent of the cases. A comorbidity is a pre-existing conditions that because of its presence with a specific diagnosis causes an increase length of stay by at least one- day in approximately 42 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 23 Definitions Medicare DRGs Non-Medicare DRGs 43 Major Diagnostic Categories (MDC) Diagnosis-related groupings have also been divided into categories that follow the body systems and function as a means to group DRGs. They are as follows: MDC 1 Diseases and Disorders of the Nervous System MDC 2 Diseases and Disorders of the Eye MDC 3 Diseases and Disorders of the Ear, Nose &Throat MDC 4 Diseases and Disorders of the Respiratory System MDC 5 Diseases and Disorders of the Circulatory System MDC 6 Diseases and Disorders of the Digestive System 44 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 24 Major Diagnostic Categories (MDC) MDC 7 Diseases and Disorders of the Hepatobiliary System and Pancreas MDC 8 Diseases and Disorders of Musculoskeletal System and Connective Tissue MDC 9 Diseases and Disorders of the Skin Subcutaneous Tissue and Breast MDC 10 Endocrine, Nutritional and Metabolic Disease Disorders MDC 11 Diseases and Disorders of the Kidney and Urinary Tract 45 continued... DRG Major Diagnostic Categories (MDC) MDC 12 Diseases and Disorders of the Male Reproductive System MDC 13 Diseases and Disorders of the Female Reproductive System MDC 14 Pregnancy, Childbirth and the Puerperium MDC 15 Newborn and Other Neonates with Conditions Originating in the Perinatal Period MDC 16 Diseases and Disorders of the Blood and Blood Forming Organs and Immunological Disorders MDC 17 Myeloproliferative Diseases and Poorly Differentiated Neoplasms 46 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 25 DRG Major Diagnostic Categories (MDC) MDC 18 Infectious and Parasitic Diseases MDC 19 Mental Disease and Disorders and Disorders MDC 20 Alcohol/Drug Use and Alcohol/Drug Induces Organic Mental Disorders MDC 21 Injury Poisonings and Toxic Effects of Drugs MDC 22 Burns MDC 23 Factors Influencing Health Status and Other Contacts with Health Services MDC 24 Multiple Significant Trauma MDC 25 Human Immunodeficiency Virus Infectious 47 continued... Example Neurosurgery DRGs (MDC1) DRG Description SIW 1 CRANIOTOMY AGE >17 W CC 4.9024 2 CRANIOTOMY AGE >17 W/O CC 3.1039 6 CARPAL TUNNEL RELEASE 0.6630 7 PERIPH & CRANIAL NERVE 2.8127 9 SPINAL DISORDERS & INJURIES 1.5820 10 NERVOUS SYSTEM NEOPLASMS W CC 2.2098 11 NERVOUS SYSTEM NEOPLASMS W/O CC 1.2891 12 DEGENERATIVE NERVOUS SYSTEM DIS 1.5144 13 MULTIPLE SCLEROSIS 1.1198 48 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 26 Example Cardiac Surgery DRGs (MDC5) DRG Description SIW 103 HEART TRANSPLANT 34.0759 104 CARDIAC VALVE PROC W CATH 8.9205 105 CARDIAC VALVE PROC W/O CATH 5.9911 106 BYPASS W PTCA 7.1890 107 BYPASS W CATH W/O PTCA 6.3165 108 OTHER CARDIO PROC 4.5258 109 BYPASS W/O PTCA OR CATH 4.6174 110 MAJOR CARDIOVASCULAR W CC 4.2513 111 MAJOR CARDIOVASCULAR W/O CC 2.8254 49 DRGs of Pregnancy, Childbirth (MDC14) DRG Description SIW 364 D&C, CONIZATION NOT MALIGNANCY 0.6178 365 OTHER FEMALE REPRO. PROCED 1.4250 366 MALIGNANCY, FEMALE SYSTEM, W CC 1.9498 367 MALIGNANCY, FEMALE SYSTEM, W/O CC 0.9887 368 INFECTIONS, FEMALE SYSTEM 0.7375 370 CESAREAN SECTION W CC 1.0677 371 CESAREAN SECTION W/O CC 0.8620 372 VAGINAL DELIVERY W COMP DX 0.7011 373 VAGINAL DELIVERY W/O COMP DX 0.5691 50 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 27 Case Mix Index The case-mix index (CMI) is the sum of the total number (N) of unique DRGs multiplied by their DRG weights (SIWs) and then divided by the total (裡N)number of cases. 裡 DRG1 X SIW 1 + DRG2 X SIW2 + DRG3 ...DRGi X SIWi 裡 N1+ N2 +N3 +Ni 51 Example Case Mix Index Calculation for Hospital A DRG Discription Discharges (N) SIW N * Discharges 1 CRANIOTOMY AGE >17 W CC 100 4.9024 490.24 2 CRANIOTOMY AGE >17 W/O CC 150 3.1039 465.585 6 CARPAL TUNNEL RELEASE 60 0.663 39.78 9 SPINAL DISORDERS & INJURIES 200 1.582 316.4 10 NERVOUS SYSTEM NEOPLASMS W CC 150 2.2098 331.47 11 NERVOUS SYSTEM NEOPLASMS W/O CC 220 1.2891 283.602 103 HEART TRANSPLANT 32 34.0759 1090.4288 104 CARDIAC VALVE PROCEDURES W CATH 220 8.9205 1962.51 105 CARDIAC VALVE PROCEDURES W/O CATH 235 5.9911 1407.9085 106 CORONARY BYPASS W PTCA 125 7.189 898.625 107 CORONARY BYPASS W CARDIAC CATH W/O PTCA 135 6.3165 852.7275 209 MAJOR JOINT&LIMB REATTACH PROC 130 3.5778 465.114 210 HIP & FEMUR PROC EX MAJOR JOINT AGE >17 W CC 155 3.4516 534.998 211 HIP & FEMUR PROC EX MAJOR JOINT AGE >17 W/O CC 230 2.2291 512.693 212 HIP & FEMUR PROCEDURES EX MAJOR JOINT AGE <18 110 2.0625 226.875 213 AMPUTAT FOR MUSCULOSKELET SYSTEM 98 2.9877 292.7946 216 BIOPSIES OF MUSCULOSKELETAL SYSTEM 75 2.6518 198.885 218 LOW EXTREM & HUMER PROC W CC 200 2.4414 488.28 370 CESAREAN SECTION W CC 250 1.068 267 371 CESAREAN SECTION W/O CC 330 0.862 284.46 372 VAGINAL DELIVERY W COMPLICATING DIAGNOSES 623 0.701 436.723 373 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES 730 0.057 41.537 999 OTHER DRGs 15000 1.000 15000 TOTALS 19558 1.375 26888.6364 52 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 28 Calculation of Hospital A - DRG Revenues CMI=1.375 Discharges=19,558 Reimbursement= $10,000 per CMI point Patient Revenues 1.375* 19,558* $10,000=$268,992,500 53 Example Case Mix Index Calculation for Hospital B 1 CRANIOTOMY AGE >17 W CC 167 4.9024 818.7008 2 CRANIOTOMY AGE >17 W/O CC 150 3.1039 465.585 6 CARPAL TUNNEL RELEASE 60 0.663 39.78 9 SPINAL DISORDERS & INJURIES 159 1.582 251.538 10 NERVOUS SYSTEM NEOPLASMS W CC 100 2.2098 220.98 11 NERVOUS SYSTEM NEOPLASMS W/O CC 150 1.2891 193.365 103 HEART TRANSPLANT 0 34.0759 0 104 CARDIAC VALVE PROCEDURES W CATH 150 8.9205 1338.075 105 CARDIAC VALVE PROCEDURES W/O CATH 200 5.9911 1198.22 106 CORONARY BYPASS W PTCA 128 7.189 920.192 107 CORONARY BYPASS W CARDIAC CATH W/O PTCA 200 6.3165 1263.3 209 MAJOR JOINT&LIMB REATTACH PROC 150 3.5778 536.67 210 HIP & FEMUR PROC EX MAJOR JOINT AGE >17 W CC 232 3.4516 800.7712 211 HIP & FEMUR PROC EX MAJOR JOINT AGE >17 W/O CC 300 2.2291 668.73 212 HIP & FEMUR PROCEDURES EX MAJOR JOINT AGE <18 500 2.0625 1031.25 213 AMPUTAT FOR MUSCULOSKELET SYSTEM 300 2.9877 896.31 216 BIOPSIES OF MUSCULOSKELETAL SYSTEM 125 2.6518 331.475 218 LOW EXTREM & HUMER PROC W CC 200 2.4414 488.28 370 CESAREAN SECTION W CC 1000 1.068 1068 371 CESAREAN SECTION W/O CC 500 0.862 431 372 VAGINAL DELIVERY W COMPLICATING DIAGNOSES 2400 0.701 1682.4 373 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES 3600 0.057 204.84 999 OTHER DRGs 20000 0.900 18000 TOTALS 30771 1.068 32849.462 54 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 29 Calculation of Hospital B - DRG Revenues CMI=1.068 Discharges=30,771 Reimbursement= $10,000 per CMI point Patient Revenues 1.068* 30,771* $10,000=$328,634,280 55 Example Case Mix Index Calculation for Hospital C 1 CRANIOTOMY AGE >17 W CC 167 4.9024 818.7008 2 CRANIOTOMY AGE >17 W/O CC 150 3.1039 465.585 6 CARPAL TUNNEL RELEASE 60 0.663 39.78 9 SPINAL DISORDERS & INJURIES 200 1.582 316.4 10 NERVOUS SYSTEM NEOPLASMS W CC 150 2.2098 331.47 11 NERVOUS SYSTEM NEOPLASMS W/O CC 220 1.2891 283.602 103 HEART TRANSPLANT 100 34.0759 3407.59 104 CARDIAC VALVE PROCEDURES W CATH 333 8.9205 2970.5265 105 CARDIAC VALVE PROCEDURES W/O CATH 436 5.9911 2612.1196 106 CORONARY BYPASS W PTCA 128 7.189 920.192 107 CORONARY BYPASS W CARDIAC CATH W/O PTCA 257 6.3165 1623.3405 209 MAJOR JOINT&LIMB REATTACH PROC 180 3.5778 644.004 210 HIP & FEMUR PROC EX MAJOR JOINT AGE >17 W CC 232 3.4516 800.7712 211 HIP & FEMUR PROC EX MAJOR JOINT AGE >17 W/O CC 490 2.2291 1092.259 212 HIP & FEMUR PROCEDURES EX MAJOR JOINT AGE <18 834 2.0625 1720.125 213 AMPUTAT FOR MUSCULOSKELET SYSTEM 449 2.9877 1341.4773 216 BIOPSIES OF MUSCULOSKELETAL SYSTEM 200 2.6518 530.36 218 LOW EXTREM & HUMER PROC W CC 200 2.4414 488.28 370 CESAREAN SECTION W CC 629 1.068 671.772 371 CESAREAN SECTION W/O CC 555 0.862 478.41 372 VAGINAL DELIVERY W COMPLICATING DIAGNOSES 2300 0.701 1612.3 373 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES 3300 0.057 187.77 999 OTHER DRGs 25000 1.500 37500 TOTALS 36570 1.664 60856.8349 56 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
Lecture 10 30 Calculation of Hospital C - DRG Revenues CMI=1.664 Discharges=36,570 Reimbursement= $10,000 per CMI point Patient Revenues 1.665* 36,570* $10,000=$608,892,250 57 Example DRG Construct (2) MDC 11 D&D of the Kidney and Urinary Tract Yes 310 Transurethral CC No 311 Yes Yes 312 OR CC No Yes 313 Urethra GT17 No 314 No Other Kidney and Urinary Tract OR Proc. 315 58 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA

More Related Content

Lecture Icd 10

  • 1. Baruch College/Mount Sinai School of Medicine Program in Health Care Administration and Policy Medical Record Coding and DRGs BUS9100 Lecture 10 Raymond R. Arons, Dr. P.H, M.P.H February 9, 2010
  • 2. Lecture 10 2 Baruch College/Mount Sinai School of Medicine Program In Health Care Administration and Policy BUS 9100: The Social and Governmental Environment of the Business of Health Care Lecture 10-February 9, 2010 Revenues, Medical Record Coding and DRGs Raymond R. Arons, Dr. P.H, M.P.H http://www.cms.hhs.gov/TheChartSeries/03_Health_Care_Facts_Figures.asp#TopOfPage Section 10.0 The Hospital Revenue Cycle Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 3. Lecture 10 3 INPATIENT REVENUE CYCLE Patient Demographics Admitted Insurance, Other To Hospital Data Captured Diagnoses (Dx.), Patient Procedures (Pr.), Discharged in Medical Record Coders take the Dx. Bill is submitted and Pr. Convert to to Insurance ICD codes for billing Company For Payment $$$ 3 Revenue Cycle Obstacles to Payment Bill is not complete and is bounced by Insurance Company Insurance ID incorrect. Other, missing elements such as secondary payer, age sex, race, ethnicity, procedure dates etc. Submission is not within the time limits. Other factors such as denials etc, Admitted within 30 days of discharge. Never received claim. Errors in medical record coding. 4 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 4. Lecture 10 4 Section 10.1 International Classification of Diseases Coding Methods Coding Methods Currently in Use International Classification of Diseases - ICD-9-CM Coding of Inpatient Discharges International Classification of Diseases - ICD-10-CM Mandated for 2013 but used as of 12/30/09 Diagnosis-related Groupings (DRGs) Hospital reimbursement -Medicare Hospital reimbursement -Non Medicare Physician Current Procedure Terminology (CPT) Physicians for procedures performed Common Procedure Coding System (HCPCS) Used by vendors of equipment and services 6 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 5. Lecture 10 5 International Classification of Diseases (ICD-9-CM) History Definitions Classification of Diseases Groupings Disease Coding Procedure Grouping Procedure Coding Other Areas such as V codes, E codes 7 ICD History Statistical classification of diseases date back to the eighteenth century with a primary focus upon the causes of death The Sixth Revision, in 1948 expanded to include non- fatal diseases. In 1950 the US Public Health Service and the Veterans Administration began independent tests of ICD-6 for hospital indexing purposes. In 1951 the Presbyterian Hospital in New York City adopted the ICD-6th Revision with some modifications for use in its record department (HCFA,1980) 8 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 6. Lecture 10 6 ICD History The Ninth revision in 1975 in Geneva included procedures in medicine and of impairments, and handicaps. ICD-9-CM became effective in January 1979 and is currently up to its latest revision to keep up with new technologies, procedures, and diseases. Over the past century, ICD was under the control of WHO, The Commission on Professional Hospital Activity and currently the Health Care Financing Administration (HCFA), and Centers for Medicare and Medicaid (CMS) ICD-10-CM was released in 1999 and will be required for physician and hospital use in 2013 and currently is optional as of December 2009 9 Definitions A classification of disease may be defined as a system of categories to which morbid entities are assigned according to established criteria. A Statistical classification of diseases must encompass the entire range of morbid conditions within a manageable number of categories (ICD-10, WHO,1992) 10 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 7. Lecture 10 7 Examples of I9 Codes Infectious and Parasitic Diseases (000-139) 042 Human immunodeficiency virus (HIV) 090.0 Early congenital syphilis,symptomatic Neoplasms (140-239) 162.2 Malignant neoplasm of the main bronchus 191.1 Malignant neoplasm of the fontal lobe Endocrine,Nutritional and Metabolic Diseases and Immunity Disorders (240-319) 250.1 Diabetes mellitus with ketoacidosis 278.01 Morbid obesity 11 continued... Examples of I9 Codes Blood and Blood-Forming Organs (280-289) 282.6 Sickle-cell anemia 285.9 Anemia, unspecified Mental Disorders (290-319) 295.4 Acute schizophrenic episode 296.3 Major depressive disorders Nervous System and Sense Organs (320-389) 332.0 Parkinsons disease with paralysis agitans 362.0 Diabetic retinopathy 12 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 8. Lecture 10 8 Examples of I9 Codes Diseases of the Circulatory System (390-459) 410.1 Acute myocardial infarction of anterolateral wall 414.0 Heart Failure Diseases of the Respiratory System (460-519) 492.0 Emphysema bleb 493.9 Asthma, unspecified Diseases of the Digestive System (520-579) 540 Acute appendicitis with generalized peritonitis 550 Inguinal hernia, with gangrene 13 continued... Examples of I9 Codes Diseases of the Genitournary System (580-629) 592.0 Calculus of the kidney 600 Hyperplasia of prostate Complications of Pregnancy and Childbirth and the Puerperium (630-676) 633 Ectopic pregnancy 634 Spontaneous abortion Diseases of the Skin and Subcutaneous Tissue(680- 709) 684 Impetigo 697.0 Lichen planus 14 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 9. Lecture 10 9 Examples of I9 Codes Congenital Anomalies (740-759) 734.61 Flat foot congenital 749.00 Clef palate, unspecified Certain Conditions Originating in the Perinatal Period (760-779) 760.0 Maternal hypertensive disorder 762.4 Prolapsed cord Symptoms, Signs and Ill-defined Conditions (780-799) 780.6 Fever 780.1 Hallucinations 15 continued... Examples of I9 Codes Diseases of the Musculoskeletal System and Connective Tissue (710-739) 714.0 Rheumatoid arthritis 722 Intervertebral disc disorder 733.1 Pathologic fracture Injury and Poisoning (800-999) 800.1 Open fracture of clavicle 952.01 C1/C4 level with complete lesion of spinal cord 16 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 10. Lecture 10 10 Examples of I9 Codes Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V01- V82) V30.00 Single live born vaginal delivery in hospital V60.3 Person living alone Supplementary Classification of External Causes of Injury and Poisoning (E800-E999) E813 Motor Vehicle traffic accident highway collision E800 Railway accident involving collision with train 17 continued... Examples of I9 Procedure Codes Operations of the Nervous System (01-05) 01.0 Cranial puncture 01.2 Craniotomy and craniectomy 03.01 Removal of foreign body from spinal canal Operations on the Endocrine System (06-07) 06.01 Aspiration of thyroid 07.8 Thymectomy Operations on the Eye (08-16) 16.3 Evisceration of eyeball 16.82 Repair of wound of orbit 18 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 11. Lecture 10 11 I9 Procedure Codes Operations of the Ear (18-20) 18.0 Incision of External Ear 20.0 Myringotomy 20.96 Implantation or replacement of cochlear prosthetic device Operations on the Nose,Mouth and Pharynx (21-29) 21.0 Control of epistaxis 21.7 Reduction of a Nasal Fracture Operations on the Respiratory System (30-34) 32.4 Lobectomy of lung 33.5 Lung transplant 19 continued... I9 Procedure Codes Operations on the Cardiovascular System (35-39) 35.2 Replacement of Heart Valve 37.5 Heart Transplant 38.5 Ligation and stripping of varicose veins Operations on the Hemic and Lymphatic System (40-41) 40.11 Biopsy of lymphatic structure 41.01 Autologous bone marrow transplant Operations on the Digestive System (42-54) 42.42 Total esophagectomy 47.0 Appendectomy 20 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 12. Lecture 10 12 I9 Procedure Codes Operations on the Urinary System (55-59) 55.5 Complete nephrectomy 55.6 Kidney Transplant Operations on Male Genital Organs (60-64) 60.2 Transurethral prostatectomy 64.5 Operation for sex transformation, NEC Operations on Female Genital Organs (65-71) 68.6 Radical abdominal hysterectomy 69.92 Artificial insemination 21 continued... I9 Procedure Codes Obstetrical Procedures (72-75) 74.0 Classical cesarean section 72.31 High forceps operation with episiotomy Operations on Musculoskeletal System (76-84) 79.85 Open reduction of dislocation of hip 81.51 Total hip replacement Operations on the Integumentary System(85-86) 85.23 Subtotal mastectomy 85.94 Removal of implant of breast 22 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 13. Lecture 10 13 I9 Procedure Codes Miscellaneous Diagnostic and Therapeutic Procedures (87-99) 87.1 Other x-ray of face, head and neck 88.4 Arteriography using contract materials 88.93 Magnetic resonance imaging of spinal canal 89.4 Cardiac stress tests and pacemaker checks 94.4 Psychotherapy and counseling 99.92 Other acupuncture 23 continued... Usage of I9 Coding Systems All discharges from hospitals, visits to physician offices, ambulatory care centers, and other sites of the delivery of care require and ICD-9-CM code that reflects the various diseases that were treated and procedures performed. All bills to third party agencies, Medicare, Medicaid, Blue Cross and other payors require diseases and procedures that were written in charts to be coded by staff prior to being submitted for payment. As of 2013 the ICD-10-CM will be required. 24 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 14. Lecture 10 14 A Sample of ECODES (Accidents) E8000 RR COLLISION NOS-EMPLOY E8001 RR COLL NOS-PASSENGER E8002 RR COLL NOS-PEDESTRIAN E8003 RR COLL NOS-PED CYCLIST E8008 RR COLL NOS-PERSON NEC E8009 RR COLL NOS-PERSON NOS E8010 RR COLL W OTH OBJ-EMPLOY E8011 RR COLL W OTH OBJ-PASNGR E8012 RR COLL W OTH OBJ-PEDEST E8013 RR COLL W OTH OBJ-CYCL E8018 RR COL W OTH OBJ-PER NEC E8019 RR COL W OTH OBJ-PER NOS 25 A Sample of VCODES V3000 SINGLE LB IN-HOSP W/O CS V3001 SINGLE LB IN-HOSP W CS V301 SINGL LIVEBRN-BEFORE ADM V302 SINGLE LIVEBORN-NONHOSP V3100 TWIN-MATE LB-HOSP W/O CS V3101 TWIN-MATE LB-IN HOS W CS V311 TWIN, MATE LB-BEFORE ADM V312 TWIN, MATE LB-NONHOSP V3200 TWIN-MATE SB-HOSP W/O CS V3201 TWIN-MATE SB-HOSP W CS V321 TWIN, MATE SB-BEFORE ADM V322 TWIN, MATE SB-NONHOSP 26 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 15. Lecture 10 15 A Sample of Burn I9 Codes 94510 1ST DEG BURN LEG NOS 94511 1ST DEG BURN TOE 94512 1ST DEG BURN FOOT 94513 1ST DEG BURN ANKLE 94514 1ST DEG BURN LOWER LEG 94515 1ST DEG BURN KNEE 94516 1ST DEG BURN THIGH 94519 1ST DEG BURN LEG-MULT 94520 2ND DEG BURN LEG NOS 94521 2ND DEG BURN TOE 94522 2ND DEG BURN FOOT 94523 2ND DEG BURN ANKLE 27 Sample of Poisoning I9 Codes 96502 POISONING-METHADONE 96509 POISONING-OPIATES NEC 9651 POISONING-SALICYLATES 9654 POIS-AROM ANALGESICS NEC 9655 POISONING-PYRAZOLE DERIV 96561 POIS-PROPIONIC ACID DERV 96569 POISON-ANTIRHEUMATIC NEC 9657 POIS-NO-NARC ANALGES NEC 9658 POIS-ANALGES/ANTIPYR NEC 9659 POIS-ANALGES/ANTIPYR NOS 9660 POISON-OXAZOLIDINE DERIV 28 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 16. Lecture 10 16 Example of I9 Cardiac Surgical Procedures 3610 AORTOCORONARY BYPASS NOS 3611 AORTOCOR BYPAS-1 COR ART 3612 AORTOCOR BYPAS-2 COR ART 3613 AORTOCOR BYPAS-3 COR ART 3614 AORTCOR BYPAS-4+ COR ART 3615 1 INT MAM-COR ART BYPASS 3616 2 INT MAM-COR ART BYPASS 3617 ABD-CORON ARTERY BYPASS 3619 HRT REVAS BYPS ANAS NEC 362 ARTERIAL IMPLANT REVASC 3631 OPEN CHEST TRANS REVASC 29 Example I9 Neurosurgery Procedures 0102 VENTRICL SHUNT TUBE PUNC 0109 CRANIAL PUNCTURE NEC 0111 CLOS CEREB MENINGES BX 0112 OPEN CEREB MENINGES BX 0113 CLOSED BRAIN BIOPSY 0114 OPEN BRAIN BIOPSY 0115 SKULL BIOPSY 0118 OTHER BRAIN DX PROCEDURE 0119 OTHER SKULL DX PROCEDURE 0121 CRANIAL SINUS I & D 0122 REMOV INTRACRAN STIMULAT 0123 REOPEN CRANIOTOMY SITE 30 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 17. Lecture 10 17 Example I9 Orthopedic Procedures 7971 CL REDUC DISLOC-SHOULDER 7972 CL REDUC DISLOC-ELBOW 7973 CL REDUC DISLOC-WRIST 7974 CL REDUC DISLOC-HAND/FNG 7975 CL REDUC DISLOC-HIP 7976 CL REDUC DISLOC-KNEE 7977 CL REDUC DISLOC-ANKLE 7978 CL REDUC DISLOC-FOOT/TOE 7979 CL REDUC DISLOCATION NEC 7980 OPEN REDUC-DISLOCAT NOS 7981 OPN REDUC DISLOC-SHOULDR 7982 OPEN REDUC-ELBOW DISLOC 31 Example of I9 Obstetrical Procedures 734 MEDICAL INDUCTION LABOR 7351 MANUAL ROTAT FETAL HEAD 7359 MANUAL ASSIST DELIV NEC 736 EPISIOTOMY 738 FETAL OPS-FACILITATE DEL 7391 EXT VERSION-ASSIST DELIV 7392 REPLACE PROLAPSED CORD 7393 INCIS CX TO ASSIST DELIV 7394 PUBIOTOMY TO ASSIST DEL 7399 OPS ASSISTING DELIV NEC 740 CLASSICAL C-SECTION 741 LOW CERVICAL C-SECTION 32 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 18. Lecture 10 18 Section 9.2 Diagnostic-Related Groupings (DRGs) System The Diagnosis-related Grouping System (DRGs) Introduction Design History Grouping Systems Major Diagnosis Categories Example DRGs Diagnosis-related grouping construct 34 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 19. Lecture 10 19 Introduction Medicare and Medicaid were adopted in 1965. Since their adoption and for the past 45 years the expenses for these federal funded programs have been uncontrollable. Many methods were attempted to reduce their annual growth. The most radical occurred in 1980 with the passage of public law PL-98-21 known as the Prospective Payment System (PPS). It mandated that hospitals rates were to be announces the prior year before they went into effect and rather than pay by a patients length of stay, payment would be by the diagnoses treated. 35 What Presidential Administration? DRG Design A system developed at Yale known as the diagnosis-related grouping system (DRG) was used as it currently is today, 29 years later. The patient variables to be used in the construction of the Diagnosis-related grouping system would consist of the information routinely collected by hospital in its current data collection and abstraction systems. These included diagnosis and procedure codes, death, age, and the existence of complications and comorbidities (CC). The system had as its goal the creation of a manageable number of DRGs to which payments would be assigned. Using the ICD-9- CM coding system was ruled out due to it having thousands of diagnoses and procedures. 36 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 20. Lecture 10 20 DRG History 1978 - HCFA funded an experiment with eighteen New Jersey hospitals having 383 DRGs as a prospective payment system. The ICD-8 coding system was used to construct the DRGs. 1979 - The ICD-9-CM based DRGs were funded for development at Yale School of Organization and Management. 1980 - Publication of the methodology used to construct the DRGs at Yale: Fetter R, Shin Y, Freeman RF, Averill R, Thomson JD.(1980) Case mix definitions by diagnosis-related groupings Medical Care, 18 (2, Supplement pp1-53). 37 continued... DRG History 1982 - All New Jersey hospitals used the DRGs for all discharges including Medicare, Medicaid and all private payors using a DRG system with 430 categories. 1983 In 1980 public law PL-98-21 was passed known as the Prospective Payment System (PPS). 2010 The DRGs are into their 28th version and are used for all Medicare discharges and applied as a classification system for all discharge abstracts.. 38 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 21. Lecture 10 21 DRG History DRGs have been exported to France and a number of the European 8 nations. The DRG system is designed by a division of 3M which has been involved in its design since its inception. New York State uses a Non-Medicare Grouper for its younger patients. It has more categories such as: The DRG 500 Series (Major Complications) The DRG 600 Series (Neonates) The DRG 700 Series (HIV) The DRG 800 Series (TB) 39 Grouping Systems A grouper is a statistical program that takes the billing claims submitted to Medicare and places them into similar clinical and resource intense groupings. Each group is assigned a relative weight based on the mean charges submitted yearly. The results are reweighing the diagnosis-related groupings (DRGs) and the basis for rates of reimbursement for following year. In addition new DRGs are created based upon the use of new technologies that are considered standards of practice. . 40 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 22. Lecture 10 22 Grouping Systems Therefore in September of each year CMS will produce a list of new adopted Medicare DRGs with estimated payments for the upcoming fiscal year The DRGs are divided into surgical or medical treatments The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. The principal procedure performed for definitive treatment rather than diagnostic or exploratory purposes, or that was necessary to treat a complication. The principal procedure is usually related to the principal diagnosis. 41 continued... Grouping Systems Complication or comorbidity (CC) are defined as: A complication is a condition that arises during the hospital stay that prolongs the length of stay one- day in approximately 75 percent of the cases. A comorbidity is a pre-existing conditions that because of its presence with a specific diagnosis causes an increase length of stay by at least one- day in approximately 42 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 23. Lecture 10 23 Definitions Medicare DRGs Non-Medicare DRGs 43 Major Diagnostic Categories (MDC) Diagnosis-related groupings have also been divided into categories that follow the body systems and function as a means to group DRGs. They are as follows: MDC 1 Diseases and Disorders of the Nervous System MDC 2 Diseases and Disorders of the Eye MDC 3 Diseases and Disorders of the Ear, Nose &Throat MDC 4 Diseases and Disorders of the Respiratory System MDC 5 Diseases and Disorders of the Circulatory System MDC 6 Diseases and Disorders of the Digestive System 44 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 24. Lecture 10 24 Major Diagnostic Categories (MDC) MDC 7 Diseases and Disorders of the Hepatobiliary System and Pancreas MDC 8 Diseases and Disorders of Musculoskeletal System and Connective Tissue MDC 9 Diseases and Disorders of the Skin Subcutaneous Tissue and Breast MDC 10 Endocrine, Nutritional and Metabolic Disease Disorders MDC 11 Diseases and Disorders of the Kidney and Urinary Tract 45 continued... DRG Major Diagnostic Categories (MDC) MDC 12 Diseases and Disorders of the Male Reproductive System MDC 13 Diseases and Disorders of the Female Reproductive System MDC 14 Pregnancy, Childbirth and the Puerperium MDC 15 Newborn and Other Neonates with Conditions Originating in the Perinatal Period MDC 16 Diseases and Disorders of the Blood and Blood Forming Organs and Immunological Disorders MDC 17 Myeloproliferative Diseases and Poorly Differentiated Neoplasms 46 continued... Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 25. Lecture 10 25 DRG Major Diagnostic Categories (MDC) MDC 18 Infectious and Parasitic Diseases MDC 19 Mental Disease and Disorders and Disorders MDC 20 Alcohol/Drug Use and Alcohol/Drug Induces Organic Mental Disorders MDC 21 Injury Poisonings and Toxic Effects of Drugs MDC 22 Burns MDC 23 Factors Influencing Health Status and Other Contacts with Health Services MDC 24 Multiple Significant Trauma MDC 25 Human Immunodeficiency Virus Infectious 47 continued... Example Neurosurgery DRGs (MDC1) DRG Description SIW 1 CRANIOTOMY AGE >17 W CC 4.9024 2 CRANIOTOMY AGE >17 W/O CC 3.1039 6 CARPAL TUNNEL RELEASE 0.6630 7 PERIPH & CRANIAL NERVE 2.8127 9 SPINAL DISORDERS & INJURIES 1.5820 10 NERVOUS SYSTEM NEOPLASMS W CC 2.2098 11 NERVOUS SYSTEM NEOPLASMS W/O CC 1.2891 12 DEGENERATIVE NERVOUS SYSTEM DIS 1.5144 13 MULTIPLE SCLEROSIS 1.1198 48 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 26. Lecture 10 26 Example Cardiac Surgery DRGs (MDC5) DRG Description SIW 103 HEART TRANSPLANT 34.0759 104 CARDIAC VALVE PROC W CATH 8.9205 105 CARDIAC VALVE PROC W/O CATH 5.9911 106 BYPASS W PTCA 7.1890 107 BYPASS W CATH W/O PTCA 6.3165 108 OTHER CARDIO PROC 4.5258 109 BYPASS W/O PTCA OR CATH 4.6174 110 MAJOR CARDIOVASCULAR W CC 4.2513 111 MAJOR CARDIOVASCULAR W/O CC 2.8254 49 DRGs of Pregnancy, Childbirth (MDC14) DRG Description SIW 364 D&C, CONIZATION NOT MALIGNANCY 0.6178 365 OTHER FEMALE REPRO. PROCED 1.4250 366 MALIGNANCY, FEMALE SYSTEM, W CC 1.9498 367 MALIGNANCY, FEMALE SYSTEM, W/O CC 0.9887 368 INFECTIONS, FEMALE SYSTEM 0.7375 370 CESAREAN SECTION W CC 1.0677 371 CESAREAN SECTION W/O CC 0.8620 372 VAGINAL DELIVERY W COMP DX 0.7011 373 VAGINAL DELIVERY W/O COMP DX 0.5691 50 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 27. Lecture 10 27 Case Mix Index The case-mix index (CMI) is the sum of the total number (N) of unique DRGs multiplied by their DRG weights (SIWs) and then divided by the total (裡N)number of cases. 裡 DRG1 X SIW 1 + DRG2 X SIW2 + DRG3 ...DRGi X SIWi 裡 N1+ N2 +N3 +Ni 51 Example Case Mix Index Calculation for Hospital A DRG Discription Discharges (N) SIW N * Discharges 1 CRANIOTOMY AGE >17 W CC 100 4.9024 490.24 2 CRANIOTOMY AGE >17 W/O CC 150 3.1039 465.585 6 CARPAL TUNNEL RELEASE 60 0.663 39.78 9 SPINAL DISORDERS & INJURIES 200 1.582 316.4 10 NERVOUS SYSTEM NEOPLASMS W CC 150 2.2098 331.47 11 NERVOUS SYSTEM NEOPLASMS W/O CC 220 1.2891 283.602 103 HEART TRANSPLANT 32 34.0759 1090.4288 104 CARDIAC VALVE PROCEDURES W CATH 220 8.9205 1962.51 105 CARDIAC VALVE PROCEDURES W/O CATH 235 5.9911 1407.9085 106 CORONARY BYPASS W PTCA 125 7.189 898.625 107 CORONARY BYPASS W CARDIAC CATH W/O PTCA 135 6.3165 852.7275 209 MAJOR JOINT&LIMB REATTACH PROC 130 3.5778 465.114 210 HIP & FEMUR PROC EX MAJOR JOINT AGE >17 W CC 155 3.4516 534.998 211 HIP & FEMUR PROC EX MAJOR JOINT AGE >17 W/O CC 230 2.2291 512.693 212 HIP & FEMUR PROCEDURES EX MAJOR JOINT AGE <18 110 2.0625 226.875 213 AMPUTAT FOR MUSCULOSKELET SYSTEM 98 2.9877 292.7946 216 BIOPSIES OF MUSCULOSKELETAL SYSTEM 75 2.6518 198.885 218 LOW EXTREM & HUMER PROC W CC 200 2.4414 488.28 370 CESAREAN SECTION W CC 250 1.068 267 371 CESAREAN SECTION W/O CC 330 0.862 284.46 372 VAGINAL DELIVERY W COMPLICATING DIAGNOSES 623 0.701 436.723 373 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES 730 0.057 41.537 999 OTHER DRGs 15000 1.000 15000 TOTALS 19558 1.375 26888.6364 52 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 28. Lecture 10 28 Calculation of Hospital A - DRG Revenues CMI=1.375 Discharges=19,558 Reimbursement= $10,000 per CMI point Patient Revenues 1.375* 19,558* $10,000=$268,992,500 53 Example Case Mix Index Calculation for Hospital B 1 CRANIOTOMY AGE >17 W CC 167 4.9024 818.7008 2 CRANIOTOMY AGE >17 W/O CC 150 3.1039 465.585 6 CARPAL TUNNEL RELEASE 60 0.663 39.78 9 SPINAL DISORDERS & INJURIES 159 1.582 251.538 10 NERVOUS SYSTEM NEOPLASMS W CC 100 2.2098 220.98 11 NERVOUS SYSTEM NEOPLASMS W/O CC 150 1.2891 193.365 103 HEART TRANSPLANT 0 34.0759 0 104 CARDIAC VALVE PROCEDURES W CATH 150 8.9205 1338.075 105 CARDIAC VALVE PROCEDURES W/O CATH 200 5.9911 1198.22 106 CORONARY BYPASS W PTCA 128 7.189 920.192 107 CORONARY BYPASS W CARDIAC CATH W/O PTCA 200 6.3165 1263.3 209 MAJOR JOINT&LIMB REATTACH PROC 150 3.5778 536.67 210 HIP & FEMUR PROC EX MAJOR JOINT AGE >17 W CC 232 3.4516 800.7712 211 HIP & FEMUR PROC EX MAJOR JOINT AGE >17 W/O CC 300 2.2291 668.73 212 HIP & FEMUR PROCEDURES EX MAJOR JOINT AGE <18 500 2.0625 1031.25 213 AMPUTAT FOR MUSCULOSKELET SYSTEM 300 2.9877 896.31 216 BIOPSIES OF MUSCULOSKELETAL SYSTEM 125 2.6518 331.475 218 LOW EXTREM & HUMER PROC W CC 200 2.4414 488.28 370 CESAREAN SECTION W CC 1000 1.068 1068 371 CESAREAN SECTION W/O CC 500 0.862 431 372 VAGINAL DELIVERY W COMPLICATING DIAGNOSES 2400 0.701 1682.4 373 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES 3600 0.057 204.84 999 OTHER DRGs 20000 0.900 18000 TOTALS 30771 1.068 32849.462 54 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 29. Lecture 10 29 Calculation of Hospital B - DRG Revenues CMI=1.068 Discharges=30,771 Reimbursement= $10,000 per CMI point Patient Revenues 1.068* 30,771* $10,000=$328,634,280 55 Example Case Mix Index Calculation for Hospital C 1 CRANIOTOMY AGE >17 W CC 167 4.9024 818.7008 2 CRANIOTOMY AGE >17 W/O CC 150 3.1039 465.585 6 CARPAL TUNNEL RELEASE 60 0.663 39.78 9 SPINAL DISORDERS & INJURIES 200 1.582 316.4 10 NERVOUS SYSTEM NEOPLASMS W CC 150 2.2098 331.47 11 NERVOUS SYSTEM NEOPLASMS W/O CC 220 1.2891 283.602 103 HEART TRANSPLANT 100 34.0759 3407.59 104 CARDIAC VALVE PROCEDURES W CATH 333 8.9205 2970.5265 105 CARDIAC VALVE PROCEDURES W/O CATH 436 5.9911 2612.1196 106 CORONARY BYPASS W PTCA 128 7.189 920.192 107 CORONARY BYPASS W CARDIAC CATH W/O PTCA 257 6.3165 1623.3405 209 MAJOR JOINT&LIMB REATTACH PROC 180 3.5778 644.004 210 HIP & FEMUR PROC EX MAJOR JOINT AGE >17 W CC 232 3.4516 800.7712 211 HIP & FEMUR PROC EX MAJOR JOINT AGE >17 W/O CC 490 2.2291 1092.259 212 HIP & FEMUR PROCEDURES EX MAJOR JOINT AGE <18 834 2.0625 1720.125 213 AMPUTAT FOR MUSCULOSKELET SYSTEM 449 2.9877 1341.4773 216 BIOPSIES OF MUSCULOSKELETAL SYSTEM 200 2.6518 530.36 218 LOW EXTREM & HUMER PROC W CC 200 2.4414 488.28 370 CESAREAN SECTION W CC 629 1.068 671.772 371 CESAREAN SECTION W/O CC 555 0.862 478.41 372 VAGINAL DELIVERY W COMPLICATING DIAGNOSES 2300 0.701 1612.3 373 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES 3300 0.057 187.77 999 OTHER DRGs 25000 1.500 37500 TOTALS 36570 1.664 60856.8349 56 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA
  • 30. Lecture 10 30 Calculation of Hospital C - DRG Revenues CMI=1.664 Discharges=36,570 Reimbursement= $10,000 per CMI point Patient Revenues 1.665* 36,570* $10,000=$608,892,250 57 Example DRG Construct (2) MDC 11 D&D of the Kidney and Urinary Tract Yes 310 Transurethral CC No 311 Yes Yes 312 OR CC No Yes 313 Urethra GT17 No 314 No Other Kidney and Urinary Tract OR Proc. 315 58 Copyright 息 2010 Raymond R. Arons, Teaneck, NJ, USA