The MS-DRG shift driven by the switch to ICD-10 will impact diagnoses throughout ICD-10-CM. Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, an AHIMA-approved ICD-10-CM/PCS trainer with more than 30 years of experience in HIM, reviews additional diagnoses, as well as how the shift will affect procedure codes.
Not otherwise specified codes
Not otherwise specified (NOS) codes offer an opportunity to improve documentation, Bryant says. "We've been hearing since way before 2009 [that] specificity is so important and we've been trying to address that with our CDI programs and coding and documentation improvement to help with DRG capture."
Those improvements need to happen even faster with ICD-10, Bryant says. Start by running a report and identifying when you are reporting NOS codes. Look closely at cases when the ICD-9-CM NOS code is in the top five position of the MS-DRG.
"Analyze those cases. Maybe we could have queried the physician for specificity or maybe there was another code that better represents the condition," Bryant says.
Chronic obstructive pulmonary disease
Coding professionals also need to look at chronic obstructive pulmonary disease (COPD) cases, Bryant says.
In ICD-9-CM, COPD codes include:
- 491.21, acute exacerbation of COPD
- 491.22, COPD with acute bronchitis
- 493.22, COPD with acute exacerbation of asthma
In ICD-9-CM, all of these codes are listed as CCs. Cases will group to MS-DRG 191 (COPD with CC) when either condition is sequenced as the principal diagnosis followed by one of the other conditions listed above as a secondary diagnosis.
In ICD-10-CM, one code, J44.1 (COPD with acute exacerbation) includes chronic obstructive bronchitis, chronic obstructive asthma, and COPD in its description, Bryant says.
Cases will group to lower-weighted MS-DRG 192 (COPD without CC/MCC) in ICD-10-CM because these additional conditions will not be coded separately.
Psychoses
In acute inpatient settings, patients may be admitted short term for psychoses, Bryant says.
ICD-9-CM cases that have code 296.20 (major depression, single episode, unspecified) sequenced as the principal diagnosis group to MS-DRG 885 (psychoses).
In ICD-10-CM, this same diagnosis is assigned to F32.9, which includes depression NOS. This will group to a lower-weighted MS-DRG 881 (depressive neuroses).
Obstetrics cases
A patient with known hypertension is admitted in active labor. The patient is found to have fetopelvic disproportion, and the physician performs a low cervical cesarean section.
In ICD-9-CM, the principal diagnosis is 660.11 (obstructed labor, obstruction by bony pelvis, delivered, with or without mention of antepartum condition). The secondary diagnoses include:
- 642.01, benign essential hypertension complicating pregnancy, childbirth, and the puerperium, delivered, with or without mention of antepartum condition, a CC
- 653.41, fetopelvic disproportion, delivered, with or without mention of antepartum condition
- V27.1, outcome of delivery, single stillborn
The principal procedure is 74.1 (low cervical cesarean section).
Together, these codes yield MS-DRG 765 (cesarean section with CC/MCC), which reimburses at $5,069 using an average hospital's blended rate, Bryant says.
With ICD-10-CM, physicians must document the specific trimester or weeks. Without this information, the scenario above would yield a completely different MS-DRG.
The principal diagnosis would be 065.4 (obstructed labor due to fetopelvic disproportion, unspecified). The secondary diagnoses would include:
- O10.019 (preexisting essential hypertension complicating pregnancy, unspecified trimester, which is not a CC or MCC
- Z37.1 (single stillbirth)
- Z3A.00 (weeks of gestation, not specified)
Together, these codes yield MS-DRG 766 (cesarean section without CC/MCC), which reimburses at $3,538 using an average hospital's blended rate, Bryant says. Coding, HIM, and CDI should run some reports on many scenarios and then analyze the MS-DRG results, Bryant says. This especially will be important when in the first 3- 4 months we see our Case Mix Index and volume of MS-DRG changing or shifting.
Identify ICD-10-PCS MS-DRG shifts
Not all of the MS-DRG shifts related to ICD-10 are related to diagnosis codes, says Bryant. Coding professionals will also see shifts involving procedure coding.
Broken hip prosthesis
Some of the shifts in procedure coding will be due to language differences between ICD-9-CM Volume 3 codes and ICD-10-PCS.
Coding professionals will need to pay attention to the difference between root operations Revision and Replacement, Bryant says.
Revision involves correcting, to the extent possible, a malfunctioning or displaced device.
Replacement involves putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part.
"Those definitions are key to identifying the differences in procedures," Bryant says. Review the definitions in ICD-10-PCS. Coding professionals must understand the definitions, not necessarily know the exact words.
A hip revision procedure will map to MS-DRG 467 (revision of hip or knee replacement with CC) with a weight of 3.4140.
However, if the physician performs a hip replacement, the procedure maps to the lower-weighted MS-DRG 470 (major joint replacement or reattachment of lower extremity without MCC).
Coding professionals will need to carefully read the operative note. Don't go by the title of the operative report, Bryant says. Physicians often use replacement and revision interchangeably so the key is reading through the narrative of the operative report, Bryant says.
Takedown of ileostomy/ileostomy closure
An ileostomy takedown reverses an ileostomy. In the initial procedure, the physician disconnects the end of the small intestine from the large intestine. The physician then routes the small intestine to an opening in the abdomen called a stoma. When the physician takes down an ileostomy, he or she reconnects the small intestine to either the colon or to an ileoanal reservoir.
In ICD-9-CM, the procedure maps to MS-DRG 345 (minor small and large bowel procedures with CC). However, in ICD-10-PCS, it shifts to MS-DRG 348 (anal and stomal procedures with CC).
The MS-DRG in ICD-9-CM is driven by code 46.51 for closure of the stoma of small intestine, Bryant says. ICD-10-PCS requires two codes for the closure of a stoma of the small intestine. The codes in ICD-10-PCS for closure of stoma are:
- 0WQFXZ2, Repair abdominal wall external approach
- 0DQB0ZZ, Repair ileum, open approach
If coding professionals report both codes, the procedure will continue to map to the appropriate MS-DRG. "This issue was receiving lots of chatter in the coding forums," Bryant says. "Education and training is needed. ICD-10-PCS is certainly part of the learning curve and will take time and energy to conquer all aspects of the code system."
Editor’s note: This article was originally published in the September issue of Briefings on Coding Compliance Strategies. Email your questions to editor Steven Andrews at sandrews@hcpro.com.