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Intro to coding : Coding Ethics and Physician Queries, quality, auditing, and severity
Terms in this set (112)
Who provides the values and ethical principles to which all coders must adhere?
The American Health Information Management Association (AHIMA) provides the Standards of Ethical Coding
when will the coding professional query the physician?
When the documentation is not complete for accurate, ehtical coding.
who must follow the confidentiality rules and ethical guidelines set by AHIMA's Code of Ethics?
Any credentialed professional who is not a member and all of its members. All persons involved with healthcare records and/or data are bound to follow.
The AHIMA Code of Ethics serves 7 purposes:
Promotes high standards of HIM practice.
Identifies core values on which the HIM mission is based.
Summarizes broad ethical principles that reflect the profession's core values.
Establishes a set of ethical principles to be used to guide decision-making and actions.
Establishes a framework for professional behavior and responsibilities when professional obligations conflict or ethical uncertainties arise.
Provides ethical principles by which the general public can hold the HIM professional accountable.
Mentors practitioners new to the field to HIM's mission, values, and ethical principles.
for clarification of conflicting, ambiguous, or incomplete information contained in the patients medical record.
not used to question the physicians judgement
examples of documentation situations that may require clarification:
-clinical indicators of a diagnosis but no documentation of the condition
-clinical evidence of a higher degree of specificity or severity
-a cause-and-effect relationship between two conditions or organism
-an underlying cause when admitted with symptoms
-only the treatment is documented (without a diagnosis documented)
-present on admission (POA) indicator status
proper Query Format
using standardized forms that have been pre-approved by the facility
they may be posed verbally. Verbal queries use conversation to generate documentation by the provider that supports the coding of a condition, diagnosis, or procedure.
to avoid non-compliance, organizations should develop specific poloes to clearly address how the documentation will be captured in the health record.
Queries whose wording is presumptive, directing, suggestive, or implies the provider is being led to make an assumption may appear as an attempt at inappropriate upcoding.
statements or questions that signal a leading query:
"Please document a diagnosis of ..."
"Are you treating the patient for a diagnosis of ...?"
"Is the patient's condition due to ...?"
"Do you agree that the patient's condition is consistent with a diagnosis of ...?"
Every facility should develop policies and procedures regarding obtaining physician clarification of documentation that affects the code assignment for significant conditions or procedures. It is not nec to query for every unaddressed issue in physician doc. The internal policies and procedures should state the situations that warrant a clarification.
The majority of the time the coding professional will query the physician.
the facility will determine if the physician will be quiried during the patients hospitalization or after discharge
Post discharge queries may be performed prior to billing(retrospective) or post billing
Who to Query
Any provider who is involved in the care of the patient is open to query. A query should be posed to the provider who generated the documentation in question
Physicians, consultants, and surgeons. Clarification of abnormal test results and resolution of conflicting documentation is typically the role of the attending physician
When to Query
Whenever documentation concerning any significantly reportable diagnosis or procedure is conflicting, ambiguous, or incomplete. "Significantly reportable" conditions or documentation situations should be clearly laid out in the query process policies.
The following criteria could be considered when evaluating documentation for possible query
Post billing queries
they are permitted, policies should address the time frame following claims generation that queries may be initiated.
When NOT to query
It is not appropriate to query the provider when there is insufficient clinical evidence in the medical record to support a query.
Queries that call into question a provider's clinical judgement are also not appropriate. For instance, if the provider documents a diagnosis of UTI secondary to E. coli, in the absence of a confirmatory urine culture, the provider should not be queried regarding the causative organism.
Improving the Query Process
Organizations should endeavor to improve their query process through identification of errors or potential issues with query compliance. Areas for improvement can be identified by establishing a practice of auditing and monitoring
should be performed on a routine basis.
Areas for monitoring may include the following
Compliance with established organizational policies
Confirmation that the query language is not leading
Confirmation that querying is appropriate
Ways organizations may consider performing an audit
should be tracked and followed up with an appropriate education and training. Organizations must make sure that no inappropriate coding action is taken based on the query.
It is recommended that the organization develop a consistent query format. Information that is usually included:
admission and discharge date
health record number
date of query
name and contact information of coding professional
reason for query
Aceeptable methods for posing a query
An approved query form, fax, secure email transmission or secure IT messaging method
All queries must include the relevant clinical indicators that indicate why a more specific or complete diagnosis or procedure is requested and ask the provider to make an interpretation of these clinical facts based on his or her professional judgement. Clinical indicators may be referenced from all areas of the medical record including diagnostic findings and provider impressions
Recording for the Query Response
it is recommended for the content of all queries and physician responses be captured. If the query is not to be retained as part of the permanent health record, the practitioner should document their query response directly in the patients record.
If there is a lack of clinical information in the record, the practitioner should document their clinical rationale for the diagnosis
When queries are not retained as part of the health record, it is recommended that organizations keep a copy as part of the administrative, business record. Responses that are documented on the query form alone should be retained as part of the permanent health record.
Are permissible if they follow the same format as written queries. Should capture the question posed to the physician, the relevant clinical information, and the physicians response. Verbal queries should be documented at the time of the query or immediately thereafter
Open ended query
Multiple choice Query
The preferred query method. This type of query outlines the clinical indicators, including where they are found in the record, and asks the physician if, based on their professional judgement, they can provide a diagnosis represented by the clinical information
Multiple choice query
This format also include all clinically relevant information, but instead of requesting an interpretation, the physician is presented with all clinically reasonable choices, regardless of the impact on reimbursement, from which to make a diagnosis. Options for "other", with an area allowing free text, "unable to determine", "not clinically sig nificant", and "integral to" should also be included, as these make multiple choice queries as open ended as possible
new diagnoses cannot be obtained from a yes/no query. This query type cannot be used when only clinical indicators of a condition are present and the diagnosis has yes to be documented. These queries can be used to determine POA, confirm diagnoses that already exist in the health record, to establish cause and effect relationships between documented conditions, and to resolve conflicting documentation from multiple providers. This type should also include the options for "other"with an area allowing free text, "unable to determine," "not clinically significant," and "integral to."
Acute blood loss Anemia Query
Often not clearly documented in the medical record, excessive bleeding causes the condition of acute blood loss anemia. This can be a result of blood loss following surgery, injury, or gastrointestinal /internal bleeding.
when a diagnosis of anemia is documented in the patients medical record along with the clinical findings suggestive of acute blood loss anemia without the physician documenting the diagnosis, then additional information might be required.
Some of the clinical indications for acute blood loss anemia might include the following
significant drop in (hematocrit & hemoglobin)
acute bleed-other sites
When preparing the open-ended query, the coding professional would indicate the documented indication(s) on the query form. Also included would be where these clinical findings are located in the medical record. The physician is asked to indicate the diagnosis that is being treated representing the clinical indicator(s).
Pneumonia diagnosis may not be clearly documented in the medical record. It is an infection of the lungs that involves the small air sacs and the tissues around them, Pneumonia is most often classified to the causative organism. The causative organism is generally identified by a sputum culture. If the physician does not specify whether or not this organism is the cause of the patients pneumonia, a pneumonia query may be indicated. This WOULD be a valid use of a yes/no query format because the diagnosis has already been established and needs to be further specified. Physician is asked to document if the organism identified in the sputum is responsible for the pneumonia.
Aspiration Pneumonia Query
Aspiration pneumonia is caused by the entrance of a foreign matter, such as food particles or oral secretions into the respiratory passages or lungs. When there are clinical findings suggestive of aspiration pneumonia documented in the patient's medical record without the physician documenting this condition, a query may be indicated to clarify the type of pneumonia. This would be a good use of a multiple choice format or open-ended type.
There are specific clinical findings that are typically present in patients with Aspiration Pneumonia condition. They may include:
impaired gag reflex (in patients that are unconscious or semi-conscious) after a stroke or brain injury
esophageal disorder (obstruction, cancer, stenosis, varices)
positive swallowing study
positive infiltrate on chest x-ray
current aspiration and/or recent vomiting
Sepsis or Severe Sepsis query
Sepsis is a systemic response to infection or other conditions. It is classified as spesis, severe sepsis or septic shock.
When the provider documents a localized or systemic infection and there are clinical findings of sepsis documented in the patients medical record, more information may be required
is sepsis with organ dysfunction
generally refers to circulatory failure associated with severe sepsis, and represents a type of acute organ dysfunction
clinical indications of sepsis:
fever or hypothermia
acute onset of confusion associated with disease process/altered mental status
positive blood culture
Sepsis with Positive Blood Cultures Query
Sometimes the documentation in the record does indicate sepsis, but the specific organism is not documented by the provider, but rather in the laboratory report. In this case, the coding professional is not allowed to code the specific organism without clarification from the provider. For example, the physician may document sepsis, The laboratory report indicates E. coli. In order to code the specifically to E. coli sepsis, a physician query is needed
a diagnosis that may appear in the medical record is uroseosis. In ICD-10-CM, this is not a condition that has a code assigned to it. It will be necessary for the coding professional to obtain a physician query to find out from the provider if the patient has a urinary tract infection, or a urinary tract infection that has progressed to sepsis. According to the Official Coding Guidelines, "urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic index, Should a provider use this term, he/she must be queried for clarification"
CMS Quality initiatives
HHS and CMS began launching quality Initiatives in 2001 to assure quality healthcare for all americans through accountability and public disclosure.
different initiatives and settings that have been developed.
ASC Quality Reporting
Electronic Prescribing Incentive Program
Home Health Quality Initiative
Hospital Quality Initiative
Hospital Value-Based Purchasing
IRF Quality Reporting
LTCH Quality Reporting
Nursing Home Quality Initiative
Outcome and Assessment Information Set (OASIS)
Physician Compare Initiative
Physician Quality Reporting System
ESRD Quality Incentive Program
Physician Quality Reporting system (PQRS)
Physicians and other eligible professionals can participate in the Physician Quality Reporting System (PQRS) by reporting quality measures information to CMS about specific services provided frequently to their Medicare patients with certain medical conditions. This information helps doctors measure the quality of care provided to Medicare beneficiaries.
Hospital Quality Initiatives
The quality program for hospitals is called the Hospital Value-based Purchasing Program, and it applies beginning in FY 2013 to payments for discharges occuring on or after Oct 1, 2012
Under the program, CMS will make value-based incentive payments to acute care hospitals, based either on how well the hospitals perform on certain quality measures or how much the hospitals performance improves on certain quality measures from their performance during a baseline period. Higher improvement=higher incentive payment
The Hospital Value-Based Purchasing Program (VBP)
a CMS initiative that rewards acute care hospitals with incentive payments for the quality of care they provide to people with medicare.
CMS is changing the way it pays hospitals, reqarding them for the quality of care they provide to medicare patients, not just the quantity of procedures they perform. The hospitals are rewarded based on how closely they follow best clinical practices and how well hospitals enhance patients experiences of care.
The Hospital VBP program was established by?
The affordable Care Act of 2010 (ACA) which added section 1886(o) to the Social Security Act. The law requires the Secrety of the Department of Health and Human Services (hhs) to establish a value-based purchasing program for inpatient hospitals.
To improve quality, the ACA builds on earlier legislation—the 2003 Medicare Prescription Drug, Improvement, and Modernization Act and the 2005 Deficit Reduction Act. These earlier laws established a way for Medicare to pay hospitals for reporting on quality measures, a necessary step in the process of paying for quality rather than quantity.
Quality Improvement Organizations
partnerships from federal and state agencies, researchers and academic experts, stakeholder and consumer organizations, providers and advocates, and federal contractors such as Quality Improvement Organizations (QIOs). QIOs can assist Medicare beneficiaries and their caregivers understand and use quality measures information in their healthcare decision-making process.
CMS contracts with one organization in each state, as well as DC, and Puerto Rico, US Virgin Islands to serve as the state/jurisdictions Quality Improvement Organization (QIO) contractor
QIO Quality Improvement Organization
private, mostly not for profit organizations, which are staffed by professionals, mostly doctors and other healthcare professionals, who are trained to review medical care and help beneficiaries with complaints about the quality of care and to implement improvements in the quality of care available throughout the spectrum of care.
How long are QIO contracts?
Three years in length, with each three-year cycle referenced as an ordinal "SOW" Scope of work
what is the mission of the QIO programs?
To improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare Beneficiaries.
What does CMS identify as the core functions of the QIO Program?
improving quality of care for beneficiaries
protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting
protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and Labor Act (EMTALA); and other related responsibilities as articulated in QIO-related law
, QIOs are required under which law?
Sections 1152-1154 of the Social Security Act.
Quality measures are tools that help measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality healthcare and/or that relate to one or more quality goals for healthcare.
CMS uses quality measures in its various quality initiatives that include quality improvement, pay for reporting, and public reporting. . Data on quality measures are collected or reported in a variety of ways, such as claims, assessment instruments, chart abstraction, and registries.
Goals of healthcare
Effective, safe, efficient, patient-centered, equitable, and timely care
Measures Management System (MMS)
developed by CMS as a standardized approach for the development of quality measures that it uses in its quality initiatives.
This system is composed of a set of business processes and decision criteria that CMS funded measure developers follow in the development, implementation, and maintenance of quality measures.
RAC (Recovery Audit Contractors)
The Centers for Medicare & Medicaid Services (CMS) has taken the next steps in the agency's comprehensive efforts to identify improper Medicare payments and fight fraud, waste, and abuse in the Medicare program by awarding contracts to four permanent Recovery Audit Contractors (RACs) Designed to guard the Medicare Trust Fund, In the Tax Relief and Health Care Act of 2006, Congress required a permanent and national RAC program to be in place by January 1, 2010.
what is the goal of the Recovery Audit Program?
to identify improper payments made on claims of healthcare services provided to Medicare beneficiaries. Improper payments may be overpayments or underpayments. Overpayments can occur when healthcare providers submit claims that do not meet Medicare's coding or medical necessity policies. Underpayments can occur when healthcare providers submit claims for a simple procedure but the medical record reveals that a more complicated procedure was actually performed.
Who might be reviewed under The recovery audit program?
hospitals, physician practices, nursing homes, home health agencies, durable medical equipment suppliers, and any other provider or supplier that bills Medicare Parts A and B.
What steps should providers take to comply with the RAC program?
-healthcare providers should consider conducting an internal assessment to ensure that submitted claims meet the Medicare rules.
identifying where improper payments have been persistent by reviewing the RACs' websites and identifying any patterns of denied claims within their own practice or facility
implementing procedures to promptly respond to RAC requests for medical records
if the provider disagrees with the RAC determination, filing an appeal before the 120-day deadline
keeping track of denied claims and correcting these previous errors
determining what corrective actions need to be taken to ensure compliance with Medicare's requirements and to avoid submitting incorrect claims in the future
The Joint Commission
one of the most recognized agencies that accredit hospitals. They create standards that hospitals must comply with in order to be accredited.
How does an organization become accredited?
they elect to become accredited, and completes an application, pays the fee, and then agrees to the survey process. There is a published manual listing all of the requirements that prove the organization is compliant with the Joint Commission's published standards. Some of the areas reviewed are privacy, security, confidentiality, ethics, training in patient rights, quality, and adherence to laws and regulations.
The Joint Commission's performance measurement and improvement initiative, which integrates outcomes and other performance measure data into the accreditation process. ORYX® measurement requirements are intended to support Joint Commission accredited organizations in their quality improvement efforts.
are publicly reported on The Joint Commission website at Quality Check® www.qualitycheck.org. The public availability of performance measure data permits user comparisons of hospital performance at the state and national levels
The Joint Commission became very interested in the development of core measure sets in early 1999 and began gathering data about the focus areas they would select. In 2001 they announced that they would include acute myocardial infarction (AMI) and heart failure (HF).
The Joint Commission also began collaborating with CMS regarding the CMS core measures of AMI and HF to align the measures so that they were the same. This was done to offer consistency to the organizations and to minimize data collection for them.
Facilities maintain indexes to allow retrieval and review of certain data such as diagnosis, procedures, or physician data. In addition there is the patient index that allows retrieval of the data by patient.
The disease and operation index, internal data
consists of a listing of the codes assigned for diagnoses and procedures to allow study/statistics/analysis of data. The codes would be arranged in numerical order so that data can be studied. For example, an organization may want to review all appendectomies performed in a certain time period, or all acute myocardial infarctions treated in a time period.
The physician Index, internal data
a listing of cases by physician. This can be identified by physician name, or a unique identifying number. The index also allows comparative data analysis by physician. A list of all of a physician's procedures or diagnoses can be reviewed for a certain period.
Other data is collected and reported to registries. The purpose of this data is for improving patient care through study and/or research. Examples of data that are reported include those reported to cancer registries, trauma registries, birth defects registries, implant registries, transplant registries, and immunization registries. Coding professionals may be involved in abstracting or identifying this information for data reporting.
Clinical Documentation Improvement (CDI)
Organizations strive to continuously improve their clinical documentation through organized clinical documentation improvement (CDI) programs (realizing that strong CDI program means hiring and training skilled CDI specialists). The purpose of a CDI program is to perform reviews of documentation for conflicting, incomplete, or nonspecific provider documentation. These reviews can be done in a concurrent and retrospective manner, with reviews usually occurring on the patient care units. These types of programs are designed to improve documentation, coding completeness, reimbursement, and severity of illness in the classification process.
who performs the CDI program?
A variety of individuals may perform this function, but it is commonly assigned to health information management (HIM) professionals, coding professionals, physicians, nurses, and other professionals with a clinical and/or coding background. much of it may occur through the physician query process.
Coders must accurately code a case according to coding conventions and which sources?
the ICD-10-CM Official Guidelines for Coding and Reporting
the ICD-10-PCS Official Guidelines for Coding and Reporting
Getting the facility the highest legitimate reimbursement. Optimizing coding requires a robust understanding of the above-listed direction as well as the reimbursement systems. These systems include the Inpatient Prospective Payment System (IPPS), the Outpatient Prospective Payment System (OPPS), and those for Inpatient Rehab, Inpatient Mental Health, and various others.
what is the IPPS system based on?
the IPPS system is based on various Diagnosis Related Groups (DRGs). For the most part, the DRG system is based on the principal diagnosis, procedures performed, and certain secondary diagnoses that may push a case into a higher weighted DRG.
These secondary conditions are referred to as what?
Complication or Comorbidities (CCs) and Major Complication or Comorbidities (MCCs).
review alternative DRGs
when more than one condition meets the definition of principal. If the medical record (and official guidance) supports it, the coder will choose the diagnosis code that will lead to the higher-weighted DRG. The accurate coding of procedures may affect the DRG and hence, reimbursement. Choosing the wrong root operation character or not coding a procedure when it meets the definition for multiple procedure coding can cause lost revenue.
Maximization carries a negative connotation in the coding arena. It refers to unprincipled techniques to increase facility reimbursement. These practices are sometimes called upcoding. Such methods include coding CCs and MCCs that do not meet the definition of secondary diagnoses. Occasionally, an unspecified condition does not qualify as a CC, but a more specific version of that condition does. Coding the more specified condition without clear documentation is not permissible. Assigning a higher-weighted DRG by sequencing as principal a condition more appropriate as secondary is also unacceptable.
Maximizing can sometimes be evident in inappropriate query techniques by CDI or Coding.
An inappropriate query may prompt the provider for additional conditions that are not clinically supported in the record. The use of "yes" or "no" questions or "choose one" options without room for clarification or addition is similarly discouraged.
upcoding on the outpatient side
Upcoding can also occur on the outpatient side of coding such as in the unbundling of testing panels.
a term used frequently in the healthcare industry. Some simply define it as "doing the right thing the right way." While optimization is permitted, maximization must be avoided for the facility to maintain a compliant position. It should be noted that compliance, fraud avoidance, and similar concepts should not be understood in the context of the occasional human error or oversight. Problematic behavior is systemic and purposeful or results from lack of training and procedures.
The process of auditing can be done either internally or externally. The primary reason to audit the coding process is to look for compliance to make sure that the codes submitted are accurate. An organization is wise to examine their data to strive for accuracy and compliance so that there are no surprises when an external audit is performed.
An internal audit is important to identify any possible risk areas, such as adherence to policies and procedures, coding guidelines, and payer regulations.
First part of the audit is monitoring, an ongoing review of documentation and code selection. Conducted on a regular basis.
To do your audit you can either do it with current staff, or bring in a consultant or company that specializes in this type of audit.
To do an audit, an adequate sample size must be selected. This means including records from each coder, each physician, a variety of record types, etc. The records selected must be randomly selected.
. An example of a random sample would be selecting a date of service and selecting every third record. The sample size must also be of adequate size to guarantee a representative sample.
selecting a record sample
An example of selecting a record would be selecting only small records or only one physician's records.
once the audit is complete and any risk areas are identified
a very important step of the audit is the follow-up for improvement. Training must be initiated to correct the problem(s). Reports are also made to the compliance officer or through appropriate channels. And after the training has been provided, monitoring must be performed to make sure that the action was effective.
Many governmental audits are being conducted to review claims to investigate improper coding/billing of procedures, services, and treatments. Really anyone who submits a claim for services can be subject to some type of investigation.
who can audit you?
MAC, RAC, ZPIC, BISC(Benefit Integrity Support Center), CERT program, QIO, Medicaid and State Programs, Private payor
what can an audit do to you?
Assess overpayment, terminate participation, exclusion from medicare, civil monetary penalties, criminal penalties
what is privileged
-oral and written communications
-comminications from the client as well as advice from the attorney and retained agents
-key issue: whether the comminication was in furtherance of obtaining legal advice
Work product prvilege
-materials prepared or assembled at the direction of counsel
-must be in anticipation of potential litigation
5 levels of appeal, medicare initial determination
-The letter notifying you of an overpayment decision is an "initial determination" that you may reppeal
lvl 1: Redetermination
lvl 3: Administrative Law Judge
lvl 4: Medicare Appeals Council
lvl 5: District court
Level 1: Redetermination
-you have 120 days from receipt of the initial determination to submit a request for "redetermination"
-but, to stop recoupment, you must submit the appeal within 30 days after receipt
-"Receipt" is presumed to be 5 days after the letter date
Level 2: Reconsideration
you have 180 days from receipt of the redetermination to submit a request for "reconsideration"
-But, to stop recoupment, you must submit the request within 60days after receipt
-last stage to submit new evidence.
Level 3: Administrative Law Judge
-60 days after receipt of the reconsideration to request an ALJ hearing
-CMS may resume recoupment
-Amount in controversy requirements
-2 year moratorium/litigation
-what type of review are you requestion, on the record? telephon, video or in person?
-Will you call witnesses?
-prepping witnesses, legal standard, effusive or terse? Cross examination
When filing an appeal, the beneficiary must be notified
What is the hierarchy of from least to greatest for legal rules governing Medicare reimbursement?
Manuals, regulations, statutes
the medical opinion of who is to be accorded deference by the Secretary of HHS and is binding unless contradicted by substantial evidence
A patients treating physician
DRGs and the inpatient prospective payment system
CMS administers Medicaid, Medicare, and other gov health insurance programs. Hospitals receive this funding through IPPS which was introduced in Oct 1983. Primarily introduced to influence the behavior of healthcare providers through financial incentives. Hospital based inpatient encounters are paid under the IPPS for those patients receiving Medicare.
Formal definition of a DRG
"a statistical system of classifying any inpatient stay into groups for the purposes of payment"
patients with similar clinical conditions, resource intensity, and costs are grouped together into a specific category for DRG. Groupers are used to assign an inpatient encounter into a DRG
Federal Register, 4 guiding principles for the formation of DRG's
1. The patient characteristics used in the DRG definition should be limited to information routinely collected on the hospital billing form.
2. There should be a manageable number of DRGs that encompass all patients seen on an inpatient basis.
3. Each DRG should contain patients with a similar pattern of resource intensity.
4. Each DRG should contain patients who are similar from a clinical perspective (i.e., each class should be clinically coherent).
Every year, CMS reviews the DRGs to ensure they accurately reflect similar clinical conditions that require similar resource consumption.
example, the treatment protocol and care rendered and the cost associated with acute respiratory failure and pulmonary edema are the same. Both patients require oxygen therapy immediately as well as nebulizer treatments and a root cause analysis of their respiratory distress.
the Two common DRG classifications used today
Medicare severity DRG (MS-DRG) and All Patients Refined DRG (APR-DRG)
MS-DRG's why developed
were developed in oct 2007 to better recognize a patients severity of illness and the associated increase in utilization of resources than the traditional CMS DRG system implemented in 1983, which did not allow for reimbursement based on multiple conditions treated during the same admission.
APR-DRG's why developed
were developed by 3M in 1990 to address both severity of illness and risk or mortality across all patient populations
MS-DRG's elements necessary to formulate
-Secondary diagnoses OR procedures performed (as defined by CMS)
-Age and sex of patient
The MS-DRG system is a three-tiered, severity-based DRG system. Under this system, the diagnoses and/or procedures represent the level of resources used to treat the patient.
A patient's principal diagnosis may group to a single tier MS-DRG or may be assigned to one in a group of up to three DRGs whose levels or tiers are differentiated by severity.
For DRGs, the lowest tier or the MS-DRG with the lowest severity is one without a CC (comorbidity or complication) or an MCC (major complication or comorbidity)
The third tier MS-DRG is one with an MCC which has the highest level of severity. With MS-DRGs, a single secondary diagnosis can change the DRG assignmen
The second tier MS-DRG is one with a CC which has a higher level of severity than the MS-DRG without a CC/MCC.
examples of tiers
Other factors such as the performance of specific procedures may also determine MS-DRG assignment.
2 tier MS-DRG Group
Lowest tier DRG in a group that is based on principal procedure - 114 Orbital procedures without CC/MCC
Highest tier DRG in a group that is based on principal procedure - 113 Orbital procedures with CC/MCC
Single tier MS-DRG
010 Pancreas transplant
2 tier MS-DRG Group
Lowest tier DRG in a group that is based on principal diagnosis - 076 Viral Meningitis without CC/MCC
Highest tier DRG in a group that is based on principal diagnosis - 075 Viral Meningitis with CC/MCC
3 tier MS-DRG Group
Lowest tier DRG in a group that is based on principal diagnosis - 188 Pleural effusion without CC/MCC
Middle tier DRG in a group that is based on principal diagnosis - 187 Pleural effusion with CC
Highest tier DRG in a group that is based on principal diagnosis - 186 Pleural effusion with MCC
The APR-DRG system is a severity-adjusted system comprised of a clinical model, severity of illness (SOI) and risk of mortality (ROM). Severity of illness and risk of mortality are divided according to the same four subclasses with a total of eight subclasses altogether for each APR-DRG.
4 subclasses of APR-DRGs
APR-DRG subclasses address patient differences relating to severity of illness and risk of mortality.
Severity of Illness (SOI)
describes the extent of the physiologic de-compensation or organ system loss of function. The risk of mortality, otherwise known as ROM, indicates the likelihood of the patient dying. Both very important concepts when determining the APR-DRG
The elements necessary to formulate an APR-DRG
-severity of illness
-risk of mortality
APR-DRGs take into account all secondary diagnoses, which can work together and contribute to moving the patient into a higher DRG assignment. In addition, the interaction among the secondary diagnoses with the patient's age, principal diagnosis, and the presence of certain O.R. and non-O.R. procedures are taken into account.
assigning the APR-DRG
starts with the primary diagnosis. The four subclasses address patient differences relating to severity of illness and risk of mortality. Severity of illness and risk of mortality relate to distinct patient attributes, so while a diagnosis may represent a major severity of illness, it could represent a mild risk of mortality. Each secondary diagnosis is assigned a severity of illness level and a risk of mortality level, and all are taken into consideration to move the patient to the highest DRG assignment possible.
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