建立你自己的疾病分型
2009-05-28 22:19阅读：
Build Your Own DRG
By Judy Sturgeon, CCS
For The Record
Vol. 20 No. 3 P. 6 To understand the diagnosis-related
group (DRG) payment system, it is necessary to accept that it
doesn’t make sense from a clinical standpoint. Some DRGs are
affected by age, while others aren’t. Some are affected by surgical
procedures performed during the encounter; others only change DRG
for transplants and tracheostomies.
A newborn with numerous health problems may end up in a DRG that
reads “Normal newborn,” while a two-day stay newborn may
legitimately be assigned to the DRG claiming to be for term
neonates with major problems. A pregnant patient can require one
month in the hospital prior to a vaginal delivery and end up in a
DRG that reads “Vaginal delivery without complicating diagnosis.”
Age, gender, and discharge status may affect the final DRG—but,
then again, they may have no effect on it at all.
A review of the grouper logic—and examples of how a
DRG is determined—can help clarify some of the seemingly
unreasonable assignments, such as those previously mentioned. In
its fundamental makeup, this system is not based on severity of
illness. While the new complication and comorbidity (CC) system
offers allowances for greater and lesser severity in secondary
diagnoses, the base DRGs are still essentially a reflection of
reported charges and/or costs of patient types. The dollar amount
to be paid for each is based on annual statistics for each
group—hence the name.
Each DRG is assigned an average length of stay and a relative
weight that helps calculate hospital payment. The key word is
average—the entire system is designed to pay the provider an
average amount of money for patients with similar types of
diagnoses and procedures rather than a payment based on the charges
or severity of illness for that specific patient. In theory, some
cases will make money and some will lose money, but it should
balance out over the year.
Determining the principal diagnosis—the reason, after study, that
caused the patient to be admitted—is the first step in identifying
the initial major diagnostic category (MDC) to which the admission
will most likely be assigned. These categories are the basic
building blocks of the DRG system and include 25 that are based on
body systems or medical specialties, one for odd stuff (surgical
procedures totally unrelated to the reason for admission and
invalid or ungroupable cases) and a separate one for transplants
and other overriding surgical scenarios. The MDC is generally
divided into a surgical side and a medical side, but even that is
not a hard-and-fast rule. Some MDCs don’t have a medical side (the
weird one); others skip the surgical side (newborns).
Once the MDC has been tentatively established, procedures performed
on the patient may move the encounter to the DRG’s surgical side.
These procedures don’t necessarily have to take place in a major
operative suite to qualify for a surgical DRG (eg, coronary stent,
excisional debridement, endoscopic lung biopsy). Neither does the
use of the operating room (OR) guarantee that a surgical DRG will
be assigned (eg, some incisions and drainages, excisions,
suturings, biopsies). Historical costs, charges, and comparative
lengths of stay have statistically determined the surgical DRGs,
not the procedure’s location.
Secondary conditions that have statistical or financial
significance may change the DRG if past statistics indicate the
need. The 2007 and earlier versions of the grouper were based on
whether 75% of patients who had a condition stayed at least one day
longer in the hospital than patients without that diagnosis.
Version 25 for fiscal year 2008 has turned this concept on its ear
by also considering if the problem rates as a 3 or 4 in the
severity-adjusted all patient refined-DRG system and by further
classifying them as simple CCs or major CCs (MCCs).
Sometimes, age changes the DRG classification for an admission.
There were many DRGs reserved for neonates and patients aged 0 to
17 in fiscal year 2007 and earlier versions. There were even
separate DRGs for patients with diabetes over or under the age of
35. However, the 2008 Medicare severity DRGs have eliminated
age-specific DRGs with the exception of those specifically for
neonates.
There are gender-specific DRGs for male and female reproductive
systems. Even discharge disposition may move the patient to a
different DRG. Neonatal DRGs depend on regular home discharge vs.
death or transfer to another acute care facility. Cardiac DRGs may
be affected by the death of a patient who had an acute myocardial
infarction (MI) during the encounter.
Last, but certainly not least, there is a hierarchy that must be
followed when more than one circumstance competes for the DRG
title. Within each MDC, there are diagnosis and procedure codes
that override others. MDCs themselves are subject to hierarchy:
There are so-called pre-MDCs that pull rank on all others and
include cases involving transplant, tracheostomy, extracorporeal
membrane oxygenation, or heart-assist system implants. There are
even DRGs that can span multiple MDCs.
With a basic understanding of the grouper logic, it is possible to
figure out the correct DRG for an admission without using grouper
software. If a patient is admitted for workup of chest pain, no
cause is found, and the patient is sent home without further ado,
the DRG will be “Chest pain” from the medical side of the MDC for
circulatory system disorders.
If the chest pain is found to be due to an acute MI and the patient
survives without significant secondary problems, the DRG will
change to “Acute MI, discharged alive, without CC/MCC” but remain
on the medical side of the same MDC. Add a diagnosis of acidosis
and move to the DRG version with CC. Add pneumonia or cardiogenic
shock and move up even further to the version with MCC. Much like
rock breaks scissors in the child’s game of hierarchy, one MCC
overrides all simple CCs for DRG assignment. Should this patient
die during the encounter but prior to any significant surgical
intervention, the DRG will assign instead to “Acute MI, expired,
with MCC.”
If the patient survives, a diagnostic cardiac catheterization will
keep the admission on the medical side of the DRG fence but add a
coronary angioplasty and the DRG changes to the surgical side.
Surgical hierarchies will struggle to claim the patient who has
additional procedures such as drug-eluting stents, pacemaker or
defibrillator implants, and coronary bypass or heart-assist device
implants. While these procedures and surgeries will change the
patient’s DRG, they still remain in the circulatory system
MDC.
Consider another MI patient who is admitted and stabilized, found
to have a suspicious spot on the lung during a preprocedure chest
x-ray, and undergoes a wedge resection of a pulmonary malignancy.
This case then escapes the circulatory system MDC and is assigned
to “Extensive OR procedure unrelated to principal diagnosis, with
CC” in the “DRGs associated with all MDCs.” If the patient
subsequently has cardiac failure and receives a heart transplant
prior to discharge, the case jumps MDCs one more time to the DRG
trio “Heart transplant: with MCC, CC, or neither” in the
pre-MDCs.
The critical fact to remember when assigning or validating a DRG is
that the codes determine the DRG, not the other way around. It
makes no difference if the DRG description sounds completely wrong
for the patient’s condition or if the length of stay is
significantly out of range of the norm. The coder or auditor may
not arbitrarily choose the DRG they like; the complex grouper logic
must be followed, and the obvious complexity makes its software a
most welcome tool for the task. If documentation to support the
diagnoses and procedures is present and the codes are assigned
correctly by coding guidelines, the DRG assigned by the grouper
logic is also correct.
— 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 nearly 20 years.
