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December 10 , 2007
Major acute care hospitals were actually looking forward to the October diagnosis-related group (DRG) changes this year. Anticipation was high for a possible 2% increase in payment to major teaching and acute care providers once the Centers for Medicare & Medicaid Services (CMS) finalized the new system that was proposed to increase payment for patients with multiple illnesses. But the final rule was certainly a disappointment in that respect. Current systems such as 3M’s All-Patient Refined version (APR-DRGs) were not implemented, nor were others that would have created multiple levels of payment based on severity of illness and risk of mortality. What was finalized in their place is a second generation of the complication and comorbidity (CC) system that we have come to know and love. The DRGs have been completely renumbered, and some complex descriptions of combination DRGs have been simplified. However, while some semblance of respect was paid to higher severity of patient illness, the fact remains that only one secondary diagnosis will affect the final payment—and only when the DRG needs one. Multiple additional patient problems will not affect payment to the hospitals, and there are many DRGs unaffected by secondary diagnoses no matter their severity or how many exist for the same patient. Adding to the dismay of those who had anticipated being on the receiving end of a severity payment system, many conditions that formerly increased payment have been deleted from the eligible lists of valid CCs. The CMS took a subset of what was left and elevated them to major CCs (MCCs) as a nod to severity adjustment, but a closer examination of that higher paying group may tempt one to rename them the “really, really major CCs.” Having a working knowledge of those that have been deleted, those that remain basic CCs, and those that qualify for MCC status is critical to hospital staff who document patient care. Coders, clinical documentation specialists, auditors, and utilization review nurses will have to familiarize themselves with the new criteria and their respective DRGs. Payers will share the pain of relearning which secondary diagnoses change remittance and what adjectives will now affect the revenue cycles of all concerned. A general summary would note that codes described as not otherwise specified (NOS) and not elsewhere classified (NEC) are at severe risk of being minimized or dropped altogether. Conditions described only as chronic share a similar fate; the term acute or those having associated serious complications are required for a significant number of diagnoses if they expect to make the short list of serious contenders. Signs and symptoms are extremely minimal on the CC list—only 23 remain from that chapter. They are nearly extinct as MCCs—only five still qualify: coma, cardiogenic shock, septic shock, shock without mention of trauma, and respiratory arrest. Diabetes has had its share of CC status changes over the years. At one time, neuropathy and renal morbidity due to diabetes would have qualified for the list. More recently, the disease would have to be described as type 1 diabetes or documented as being uncontrolled during the hospital admission. Now, even these qualifiers have been removed from both standard and MCC lists in the new scheme. There are no 250 section codes on the list of basic CCs. Hypoglycemic coma and diabetes insipidus are included, but diabetes mellitus (DM) is not represented. DM reappears on the MCC list but only if documentation includes the patient as having ketoacidosis, hyperosmolarity, or coma due to the diabetes. The urinary system has seen some familiar secondary diagnoses dropped from financial significance. Both hematuria and urine retention no longer make the grade for either CC list. Urinary tract infection not further specified, chronic renal failure, acute cystitis, and hydronephrosis are still on the regular list of qualified diagnoses. However, to achieve MCC status, the patient will have to be diagnosed with acute renal failure or suffer a nontraumatic bladder rupture from the urine retention. Cardiovascular problems were similarly pared away from payment possibilities. Congestive heart failure (CHF) will not change a DRG as a secondary diagnosis without further explanation. Left heart failure, chronic or unspecified systolic or diastolic heart failure, or combined systolic/diastolic heart failure not specified as acute will make CC status. To be included as an MCC, the patient must be documented as having acute systolic or acute diastolic heart failure as part of the diagnostic statement. Acute-on-chronic systolic heart failure or acute combined systolic and diastolic heart failure are examples of complex diagnostic statements that are MCCs for CHF patients. Also missing in action are atrial fibrillation and angina NOS, neither of which now qualify as CCs at any level. Still making the grade as standard cardiac CCs are atrial flutter, some severe heart blocks, unstable angina, and postmyocardial infarction syndrome. An initial episode of care for an acute myocardial infarction will still move DRGs to include an MCC if other factors allow for that consideration. Only if the patient is discharged alive will ventricular fibrillation, cardiogenic shock, and cardiac arrest be considered MCCs. Also vanished like CC dinosaurs are dehydration, volume overload, hyperkalemia, and hypovolemia. To be considered for payment at the midlevel, the documentation must describe hypernatremia or hyponatremia, hyperosmolarity or hypoosmolarity, acidosis, or alkalosis. Malnutrition still makes the junior grade for CCs, but the metabolic or nutritional problems will have to put the patient in acute renal failure or be described as more specific and severe types of malnutrition. Chronic blood loss anemia is no longer on either list. Acute blood loss anemia and several types of hemolytic anemia still have some DRG impact as basic CCs, as do melena, hemoptysis, and gastrointestinal bleed NOS. Diagnoses that would be major CCs include gastric and intestinal ulcers documented as including hemorrhage, perforation, or obstruction. In the same vein, causes of anemia are also impacted. Unspecified thrombocytopenia is no longer a CC; coagulopathy NOS remains a basic CC, but it takes disseminated intravascular coagulopathy to be considered a major complicating diagnosis. Simple skin ulcer NOS or other specified site still won’t be a CC; there must be a documented lower limb site. Decubitus ulcers of the elbow, unspecified sites, or sites not named on the MCC list are at least basic CCs. Only decubitus ulcers specified as being located on the back, hip, buttocks, ankle, or heel will be MCCs. If you are a coder currently admitted to an acute care hospital for another problem and the impact of what you have read here causes you to have a seizure, it won’t qualify your DRG for a CC. You’d need to have a febrile seizure to meet basic CC criteria. For an MCC diagnosis, your physician will have to document that you progressed to petit mal or grand mal status or to status epilepticus. Whether we agree and whether we like it, hospital staff must learn the new system and adjust to its documentation needs. There may not be as significant a payment increase as was anticipated, but the CMS has effectively split its CC lists into more—and less—severe diagnoses. Those that were once CCs but have been deleted failed to meet severity of illness criteria in some way. If they were a non-CC in APR-DRGs and only generated a level 1 severity in APR-DRGs, they were deleted in the new system this year. So pull out your query forms, schedule your physician inservices, and let’s make 2008 another documentation and financial challenge well met by the medical community. — Judy Sturgeon, CCS, is the hospital coding senior manager at The University of Texas Medical Branch in Galveston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and appeal management for the past 18 years. Resource
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