DRGs for procedures unrelated to the principal diagnosis shouldn’t occur frequently. If they do, coding managers should take a closer look at coding compliance efforts to ensure accuracy and avoid costly audits.
Unrelated DRGs, as they’re more succinctly known, include the following:
- 981-983 (extensive operating room procedure unrelated to principal diagnosis with MCC, with CC, and without CC/MCC, respectively)
- 984-986 (prostatic operating room procedure unrelated to principal diagnosis with MCC, with CC, and without CC/MCC, respectively)
- 987-989 (non-extensive operating room procedure unrelated to principal diagnosis with MCC, with CC, and without CC/MCC, respectively)
“Avoid these DRGs when possible, but you have to realize that there are certain circumstances when they’re right, and you don’t try to avoid them when they’re right,” says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.
Cheryl Ericson, MS, RN, CCDS, CDIP, clinical documentation improvement (CDI) education director at HCPro, Inc., in Danvers, Mass., agrees. “It’s not that you’re never going to have these cases, it’s just that you should always be diligent in verifying that it’s an accurate DRG assignment,” she says.
Gold recently performed an analysis of 2012 MedPAR data and found that approximately 2.27% of all national surgical DRGs reported are those for which the principal diagnosis is unrelated to the operating room procedure.
“If your hospital is reporting considerably more than 2.27%, then you’re probably going to be a Recovery Auditor target,” says Gold. He says he’s aware of one hospital at which 80% of its surgical DRGs were unrelated DRGs. “They were at risk for tens of millions of dollars in fines over the last seven years,” he adds.
How they’re triggered
Unrelated DRGs essentially occur when a patient presents to the hospital with one diagnosis and needs surgery for a different diagnosis. Sounds simple, right?
Not quite. Keep in mind that unrelated DRGs are technically only triggered when the surgical procedure and principal diagnosis aren’t classified in the same major diagnostic category or body system within the DRG classification system, says Ericson.
For example, a patient is admitted to the hospital due to a stroke. While in the hospital, he or she falls and requires hip surgery. The stroke (principal diagnosis) is unrelated to the hip surgery (principal procedure) because the two are classified in completely different body systems (i.e., nervous system vs. musculoskeletal system), explains Ericson. This is an example of an unrelated DRG that is triggered appropriately, she adds.
“The irony with this example, though, is that you have to look at the concept of HACs [hospita-acquired conditions]. You can’t get reimbursed for the MCC associated with the hip fracture since the fracture wasn’t [present on admission] … but you can still bill a surgical DRG, and it would go to DRG 983,” says Ericson. “It’s sort of a loophole. You get less money, but you’re not really being punished to the fullest extent because you can still receive a surgical DRG, which is typically reimbursed at a higher rate compared to a medical DRG.”
Coders can’t rely on assumptions when determining whether a diagnosis and procedure are related. For example, a patient is admitted due to pneumonia. While in the hospital, he or she must undergo excisional debridement for an ulcer. Coders may assume that reporting the pneumonia with debridement would result in an unrelated DRG; however, this isn’t the case.
“Because excisional debridement is in every body system within the DRG classification system, you won’t go to an unrelated DRG even though it seems bizarre that excisional debridement would be related to a respiratory system condition,” says Ericson.
Unrelated DRGs tend to occur more frequently in tertiary care centers or regional academic medical centers. “Sometimes, these centers have all of this technology available, and they can perform all of these exhaustive workups and may find other issues while the patient is in the hospital,” says Ericson. These “other issues” can lead to operative procedures that may be unrelated to the principal diagnosis. However, any hospital can struggle with unrelated DRGs, which is why it’s important to monitor data and take steps to improve compliance when appropriate, she adds.
Why they’re a target
Normally, DRGs capture the resources associated with treatment for a particular nonsurgical disease. However, unrelated DRGs must account for unanticipated resources that require a patient to undergo an operative procedure for a condition that isn’t related to the reason for admission, Gold explains.
Therefore, these unrelated DRGs carry a much higher weight than their counterparts that include an operative procedure for the intended diagnosis. This higher weight makes them a target for the OIG as well as other auditors, he adds.
Correct assignment of the principal diagnosis is paramount. For example, a patient is admitted to the hospital due to pneumonia. While in the hospital, lab results reveal that the patient has a low red blood cell count. The red blood cells are pale and small, and the patient also has blood in his stool. After recovering from the pneumonia, the patient undergoes a colonoscopy that reveals colon cancer. The patient then undergoes a colon resection. In this case, even though the patient underwent a colon resection, the principal diagnosis is pneumonia-not colon cancer, says Gold.
“When there are two diagnoses that lead to treatment, you need to look at the circumstances of admission. It was the pneumonia that led to the admission. Nobody knew that the patient was anemic,” he adds.
Some consulting companies incorrectly advise coders to do the opposite, says Gold. “There are a lot of companies that teach people to cheat,” he says. “They say that if a patient comes to the hospital with two coprincipal diagnoses, one of which leads the patient to the operating room, coders should choose the other one as the principal diagnosis.”
Coders should also pay close attention to assigning the principal procedure. Coding Clinic, Fourth Quarter 2012, p. 80, states that when a physician performs more than one procedure, coders should choose the procedure most closely related to the principal diagnosis as the principal procedure. For example, a patient presents to the hospital with severe headaches and is taken to the operating room for a biopsy that reveals the patient has brain cancer. Postoperatively, the patient has a significant rectal bleed from hemorrhoids and is taken to the operating room for ligation of bleeding hemorrhoids.
“You can’t choose the brain cancer and ligation of the hemorrhoids because they’re not related to each other. You choose the brain cancer and the brain biopsy. If you choose any other combination, you’ll get an unrelated DRG,” says Gold. Although there is no definitive guidance stating the reverse to be true (i.e., coders should choose the condition that most closely relates to the principal procedure as the principal diagnosis), logic indicates that this is likely the case, he says.
Beware of incidental findings when determining the principal diagnosis, says Gold. For example, a patient is admitted to the hospital for an open gallbladder surgery to remove gallstones. While in the hospital, she undergoes a urinalysis that is positive for a UTI. Coders may inappropriately select the incidental UTI finding as the principal diagnosis when, in fact, the patient has actually been admitted to the hospital for gallstones. Selecting the UTI will incorrectly result in an unrelated DRG, he adds.
A robust CDI program can help providers understand the importance of documenting the condition that prompted the admission, says Ericson. “A goal of CDI is to educate providers to document in such a way that all those who review the medical record will come to the same conclusion while retaining the intent of the provider,” she adds.
Three-day rule
The three-day rule, which requires hospitals to include relevant outpatient services on the inpatient claim when they occur within three days of admission or on the same day of admission, can certainly throw a monkey wrench into a hospital’s compliance efforts, says Ericson. She says one of the most frequent reasons why hospitals incorrectly trigger unrelated DRGs is because their billing software automatically merges all outpatient charges into the inpatient claim when those charges occur within three days of an inpatient admission.
To avoid this, coders should manually review claims to ensure that only the following information is included in the patient claim:
- All outpatient services provided on the date of admission
- Any outpatient diagnostic services provided within three days of admission that are related to the admission
- Any nondiagnostic services that are clinically related to the admission
Questions to ask
Coders should ask the following two important questions when reviewing unrelated DRGs:
- Did the patient have any outpatient procedures within three days that were bundled into the inpatient claim? If so, are they appropriate and related to the inpatient admission?
- Does the diagnosis sequencing affect the DRG assignment? If the principal and major secondary diagnoses were reversed, would the case still trigger an unrelated DRG? Pay close attention to coequal conditions to ensure that they are truly coequal, Ericson says. This scenario should be rare, and coders should look at the circumstances of admission before selecting the principal diagnosis. “Unless there is an etiology/manifestation pair or something in the tabular list that specifies sequencing, you have to think about why the patient is being admitted,” she adds. Two conditions that appear to be equal may not actually be equal if one of them required a surgical intervention.
This article was originally published in the April 2013 issue ofBriefings on Coding Compliance Strategies.