DRG Desk Reference The ultimate resource for improving DRG assignment practices Contents Contents Introduction ..................................................................................................... 1 DRG History ....................................................................................................................1 Basic Characteristics of DRG Classification ......................................................................2 DRG Assignment Process .................................................................................................7 Government Scrutiny .......................................................................................................7 Keys to a Financially Successful DRG Program ................................................................8 The Future .......................................................................................................................9 DRG Desk Reference Organization ....................................................................................9 Instructions for Using Your DRG Desk Reference ........................................................... 11 Key Fields for Coder Abstracting ................................................................... 19 Abstracting Basics ......................................................................................................... 19 Standard Abstracting Elements ..................................................................................... 19 Key Fields for DRG Reimbursement .............................................................................. 21 Code Edits .................................................................................................................... 24 Compliance Issues Related to Abstracting ..................................................................... 25 DRG Assignment Tutorial .............................................................................. 29 Importance of Accurate DRG Assignment ..................................................................... 29 Why Coding Accuracy Is Not Enough .......................................................................... 29 The Components of DRG Coding and Management ...................................................... 31 Pulling it all Together ................................................................................................... 39 Evaluating the Results ................................................................................................... 42 Tools for Data Quality: Focus on Inpatient Documentation for Coding ........................ 48 DRG Decision Trees ....................................................................................... 63 Optimizing Tips ........................................................................................... 121 Nervous System, MDC 1 ............................................................................................. 125 Eye, MDC 2 ................................................................................................................ 142 Ear, Nose, Mouth, and Throat, MDC 3 ....................................................................... 145 Respiratory System, MDC 4 ........................................................................................ 152 Circulatory System, MDC 5 ......................................................................................175 Digestive System, MDC 6 .........................................................................................223 Hepatobiliary System & Pancreas, MDC 7 ................................................................243 Musculoskeletal System, MDC 8 ................................................................................. 249 Skin, Subcutaneous Tissue & Breast, MDC 9 .............................................................. 270 Endocrine, Nutritional & Metabolic Disorders, MDC 10 ..........................................279 Kidney and Urinary Tract, MDC 11 ..........................................................................285 Male Reproductive System, MDC 12 ........................................................................297 Female Reproductive System, MDC 13 ....................................................................... 302 Pregnancy, Childbirth & Puerperium, MDC 14 .......................................................... 305 Newborns & Other Neonates, MDC 15 ...................................................................... 308 Blood & Immunological Disorders, MDC 16 .............................................................. 310 Neoplasms, MDC 17 ................................................................................................... 313 Infectious & Parasitic Diseases, MDC 18 ..................................................................318 Mental Diseases & Disorders, MDC 19 .....................................................................320 Alcohol/Drug Disorders, MDC 20 ............................................................................... 321 ©2003 Ingenix, Inc. iii DRG Desk Reference Injuries, Poisonings & Toxic Effects of Drugs, MDC 21 ...............................................................................................323 Burns, MDC 22 ...........................................................................................................330 Health Status Factors, MDC 23 .................................................................................334 Multiple Significant Trauma, MDC 24 .........................................................................335 HIV Infections, MDC 25 ..............................................................................................336 Other DRGS, DRGs Associated with All MDCs and Pre-MDCs ....................................337 Complications and Comorbidities (CC) List ................................................341 Most Commonly Missed CC Conditions ......................................................359 CC Principal Diagnosis Exclusion List .........................................................381 Abnormal EKGs ............................................................................................425 Abnormal Tracing Documentation ..............................................................................425 Abnormal Laboratory Values ........................................................................435 Drug Usage ...................................................................................................467 Organisms .....................................................................................................483 Major Cardiovascular Complications & Complex Diagnosis List ................489 Implications of Complex Cardiovascular Diagnoses ....................................493 Noninvasive Diagnostic Test Outcomes .......................................................517 Cardiology Procedures ...............................................................................................517 Neurology Procedures .................................................................................................518 Pulmonary Function Tests ..........................................................................................518 Radiology Procedures .................................................................................................518 Durable Medical Equipment (DME) and Supplies .......................................523 Durable Medical Equipment (DME) ............................................................................523 Supplies ......................................................................................................................529 Developing an Effective DRG Audit Process ................................................533 Introduction ................................................................................................................533 Internal Corporate Coding Compliance Program .........................................................533 Impacts of “Undercoding”—Lost Revenue ...................................................................535 The Basics of Coding Reviews .....................................................................................536 DRGs to Review ..........................................................................................................541 Additional Information TARGET DRGs .......................................................................541 Targeted DRG Listing ...................................................................................545 New Medical Services and Technologies Under IPPS ..................................663 Criteria for Identifying New Medical Services and Technology .................................664 High-dose Infusion Interleukin-2 (IL-2) ......................................................................664 Add-on Payment for New Services and Technologies ..................................................665 Application of Coding for New Technology and Medical Services ICD-9-CM Codes ...666 ICD-10-PCS: A Possible Long-term Solution ...........................................................667 ICD-10-CM Coding System .........................................................................................667 DRG List .......................................................................................................669 Glossary ........................................................................................................689