I.    The new MS-DRGs

Since October 1^st, 2007, Hospital Coders in the US have been coding and grouping the Medicare cases by using the new MS-DRGs.  Like everything else in life, when we have no choice, we have to swim or sink.

CMS was concerned that the new MS-DRGs will provide an opportunity for Hospitals to document and code information contained in the medical record in a way that may result in a higher payment under the IPPS.  HIM professionals and coders have to follow a code of Ethics.  Unbundling, fragmenting and fraud will lead you and your facility to extensive and costly audits.  So Coders: BEWARE.

DRG assignments are based on the reporting of ICD-9-CM diagnosis and procedure codes.  The MS-DRGs are also based on the principal diagnosis, and up to eight additional diagnoses and up to six procedures.

The new MS-DRGs will increase the number of DRGs from 538 to 745.  The MS-DRGs still have cases with or without CCs, but added an additional severity level by designating certain diagnoses as Major CCs, which would have the highest weight.

152 DRGs divide into three subgroups: Major CCs, CCs without MCC, CC.

106 DRGs divide into two severity-level subgroups.  The new MS-DRGs have 3.343 codes that count as CCs.  Chronic conditions without a significant acute manifestation will not count as either CCs or major CCs.

I feel confident that the literature from the October 4^th meeting was and still is very informative to the Coders and to their supervisors.  Your physicians have learned by now that CHF has to be with systolic or diastolic or with both systolic and diastolic acute or chronic or with acute and chronic.  Dr. Weiss from St. Francis Hospital informed me that, we physicians do not know the difference between systolic and diastolic CHF.  Educate your physicians, by having a cardiac specialist talk to the physicians one physician at a time.  Share with them that the reimbursement is double the amount when CHF is with systolic or diastolic or both.

II.     Reporting Hospital-Required Conditions

A.   Complications such as infections acquired in the Hospital can trigger higher payments due to the presence of a CC.  As of October 1^st, 2007, the DRA requires CMS to identify at least two secondary diagnoses that:

• Are high cost, high volume or both
• Result in the assignment of a case to a DRG that has higher payment when present as a secondary diagnosis; and
• Could reasonably have been prevented through the application of evidence-based guidelines.

For discharges occurring on or after October 1^st, 2008, hospitals will not receive additional payment for cased where one of the selected conditions was not present on admission.

B.   Beginning October 1^st, 2008, (F.Y. 2009) CMS will consider implementing the following

conditions:

• Serious preventable event- Object left in during surgery.
• Serious preventable event- Air Embolism.
• Serious preventable event- Blood incompatibility.
• Catheter- Associated Urinary Tract Infection.
• Pressure Ulcers (Decubitus Ulcers)
• Vascular Catheter- Associated infection.
•   Surgical site infection- Mediastinitis after Coronary Artery Bypass Graft Surgery.
• Hospital Acquired Injuries- Fractures, Dislocations, Intracranial Injury, Crushing Injury, Burn and other unspecified Effects of External causes.

A complete list of all ICD-9-CM codes associated with the above conditions can be found at www.cms.hhs.gov/AcutInpatientPPS/downloads/HospitalAcqConTraumaCodes.pdf.

C.   The DRA also requires hospitals to identify secondary diagnoses that are present on admission.

We in NYS have been doing this for more than two decades.  Do not be afraid to us “0”, zero, when unknown or “2”, two, when that condition happened after admission to the Hospital.

II.        To all the members of LIHIMA who are involved with coding, make sure that your Medical Director, your Administrator/ CEO and yourself “implement a clinical documentation improvement plan to completely and appropriately identify the conditions that represent the patient’s severity of illness and determine whether conditions were or were not present on admission.” (JAHIMA, Nov, Dec 2007 Page 86)

      Peter Micallef, RHIA, CCS

      LIHIMA President