DRG Coding Advisor: AHIMA director discusses 2003 DRG coding updates

Trend is toward more specificity

The Centers for Medicare & Medicaid Services (CMS) is moving coding away from the previous trend of permitting coders to group a variety
of diagnoses under unspecified codes. Now there’s an emphasis on finding a very specific code to describe the diagnosis, says Sue Prophet-Bowman, RHIA, CCS, director of coding policy and compliance for the American Health Information Management Association (AHIMA) in Chicago.

Under the changes for fiscal year 2003, which took effect Oct. 1, 2002, most of the new DRGs and all of the ICD-9 codes require better documentation and understanding of the medical record, medical processes, and procedures, Prophet-Bowman says.

"So it definitely emphasizes the need for well-educated, qualified coding staff," she notes. "All of the complexities point to the need for greater coding skills because there are getting to be a lot more nuances in discriminating between selected codes."

"It just helps us to have better data about what conditions patients have, so we see it as a very positive trend," she adds.

One of the more interesting changes to the DRGs has been the revisions to the stroke DRGs. CMS decided that the code for the generic, nonspecific stroke should be moved to the previous coding for transient ischemic attack, Prophet-Bowman says.

"They did this mainly because data showed that patients who did not have specific cerebrovascular accident codes, indicating cerebral hemorrhage, didn’t consume as many resources," she explains. "It doesn’t mean that you have a lesser stroke, but it just has not been identified which kind of stroke you had."

This change means it is critical for coders to have complete and accurate documentation of the nature of a stroke, because without the documentation the coder will have to use a lesser DRG, Prophet-Bowman says.

AHIMA’s complete analysis of the final rule for fiscal year 2003 DRG revisions to the hospital inpatient prospective payment system (PPS) are described on the AHIMA web site at www.ahima.org/dc/DRGanalysisFY03.html.

In her analysis, Prophet-Bowman offers these examples of DRG coding changes that offer clearer descriptions and may require more specific information and better documentation:

  • DRG 1: Old DRG description read: "Craniotomy Age >17 Except for Trauma." The new DRG description reads: "Craniotomy Age >17 with complication/comorbidity."
  • DRG 2: Old DRG: "Craniotomy for Trauma Age >17." New DRG: "Craniotomy Age >17 without complication/comorbidity."
  • DRG 14: Old DRG: "Specific Cerebrovascular Disorders Except Transient Ischemic Attack (TIA)." New DRG: "Intracranial Hemorrhage and Stroke with Infarction." Also, codes 437.3 for cerebral aneurysm, nonruptured, and 784.3 for aphasia have been moved from DRG 14 to DRGs 34 and 35.
  • DRG 15: Old DRG: "Transient Ischemic Attack and Precerebral Occlusions." New DRG: "Nonspecific Cerebrovascular Accident and Precerebral Occlusion without Infarction." Also, code 436 for an acute but ill-defined cerebrovascular disease has been moved from DRG 14 to DRG 15.
  • DRG 524: Old DRG: none. New DRG: "Transient Ischemia." Also, this new DRG is now assigned codes that previously were assigned to DRG 15, including the following:

— 435.0: basilar artery syndrome;

— 435.1: vertebral artery syndrome;

— 435.2: subclavian steal syndrome;

— 435.3: vertebrobasilar artery syndrome;

— 435.8: other specified transient cerebral ischemias;

— 435.9: unspecified transient cerebral ischemia.

  • New code 277.02: This new code for cystic fibrosis with pulmonary manifestations has been assigned to DRG 79, which is described
    as "Respiratory Infection and Inflammations Age >17" to DRG 80, which is described as "Respiratory Infections and Inflammations Age >17 without complication/comorbidity" and to DRG 81, which is described as "Respiratory Infections and Inflammations Age 0-17."
  • New code 277.03: This new code for cystic fibrosis with gastrointestinal manifestations has been assigned to DRG 188, which is described as "Other Digestive System Diagnoses Age >17 with complication/comorbidity;" DRG 189, described as "Other Digestive System Diagnoses Age >17 without complication/comorbidity" and DRG 190, which is "Other Digestive System Diagnoses Age 0-17."
  • New code 277.09: This new code for cystic fibrosis with other manifestations has been classified to the same DRGs as code 277.00.
  • New DRG 525: This new DRG is for implantation of heart assist systems. It consists of any principal diagnosis in MDC 5, plus one of the following surgical procedures:

— 37.62: implant of other heart assist system;

— 37.63: replacement and repair of heart assist system;

— 37.65: implant of an external, pulsatile heart assist system;

— 37.66: implant of an implantable, pulsatile heart assist system.

  • Code 86.07: This code for insertion of totally implantable vascular access device has been assigned to DRG 315, which is defined as "Other Kidney and Urinary Tract OR [operating room] Procedures."
  • Code V10.53: This code for the history of malignancy, renal pelvis, has been assigned to DRG 465, which is defined as "Aftercare with History of Malignancy as Secondary Diagnosis."
  • DRG 483: This code has been revised with definition of "Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnoses Except Face, Mouth, and Neck." As part of its change, code 96.72, covering all cases involving a tracheostomy and a diagnosis of face, mouth, and neck diagnosis that also have been on continuous mechanical ventilation for greater than 96 hours, has been moved from DRG 482 (Tracheostomy for Face, Mouth and Neck Diagnoses) to DRG 483, a higher-weighted DRG.
  • New DRG 526: Defined as "Percutaneous Cardiovascular Procedure with Drug-Eluting Stent with Acute Myocardial Infarction," this DRG has been created for the insertion of drug-eluting coronary stents. This code will not be effective until discharges occurring on or after April 1, 2003, because the procedure has not yet been approved by the Food and Drug Administration (FDA).
  • New DRG 527: This code is defined as "Percutaneous Cardiovascular Procedure with Drug-Eluting Stent without Acute Myocardial Infarction." It will not be effective until discharges occurring on or after April 1, 2003, because the procedure has not yet been approved by the FDA.
  • New code 00.11: Defined as "Infusion of drotrecogin alfa [activated]," this new code will be used in cases where Xigris, approved for an add-on payment as a new technology, is administered. Xigris is used to reduce mortality in adults with sepsis associated with organ dysfunction and who have a high risk of death. It’s a biotechnology product that was approved by the FDA in November 2001.
  • New code 00.50: Defined as "Implantation
    of cardiac resynchronization pacemaker without mention of defibrillation, total system [CRT-P]," this code has been assigned to DRG 115, which is for "Permanent Cardiac Pacemaker Implantation with Acute Myocardial Infarction, Heart Failure, or Shock, or AICD Lead or Generator Procedure," and DRG 116, which is "Other Permanent Cardiac Pacemaker Implant."
  • New code 00.51: Defined as "Implantation
    of cardiac resynchronization defibrillator, total system [CRT-D]," this code has been assigned to DRG 514, which is "Cardiac Defibrillator Implant with Cardiac Catheterization," and DRG 515, which is "Cardiac Defibrillator Implant without Cardiac Catheterization."
  • Code 57.87: Defined as "Reconstruction of urinary bladder," this code has been assigned as a major bladder procedure to DRG 303 (Kidney, Ureter, and Major Bladder Procedures for Neoplasm), DRG 304 (Kidney, Ureter, and Major Bladder Procedures for Nonneoplasm with complication/comorbidity), and DRG 305, which is "Kidney, Ureter, and Major Bladder Procedures for Nonneoplasm without complication/comorbidity."
  • Code 398.91: This code for rheumatic heart failure has been moved from DRG 125 to DRG 124, which is "Circulatory Disorders Except Acute Myocardial Infarction with Cardiac Catheterization and Complex Diagnosis."