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Congenital Anomaly ICD-10-CM/PCS Coding and DRG Implications Elsevier Clinical Solutions Presented By: Deborah Gardner- Brown, RHIT,CCS,CDIP,CCDS,C-CDI,CICDI,CCMSCP,CPMA July 21, 2016 Objectives Recall the logic for assigning congenital anomaly diagnoses to surgical/procedural DRGs Evaluate the difference between MS-DRGs and APR-DRGs for surgical/procedures for congenital anomaly diagnoses Identify the major procedures that link to surgical/procedural DRGs for congenital anomaly diagnoses Differentiate the Condition Congenital Anomaly/Malformation/Disorder • Congenital anomaly/malformation: A physical defect present in a baby at birth that can involve many different parts of the body. Congenital malformation can be genetic, it can result from exposure of the fetus to a malforming agent (such as alcohol), or it can be of unknown origin. Examples include heart defects, cleft lip and palate, spina bifida, limb defects, and Downs syndrome. Codes Q00-Q89 • Congenital disorder: Also known as congenital disease, birth defect or anomaly, is a condition existing at or before birth regardless of cause. Birth defects vary widely in cause and symptoms. Any substance that causes birth defects is known as a teratogen. Some disorders are detected before birth through prenatal diagnosis. Codes P052- P962 Gather all the Facts Examine the history - Diagnoses, disorders, syndromes, and specific anomaly. • Is the condition actively present? • Does it require surgical correction? • Is it a past (corrected) personal history? • Identify active problems/conditions and determine the body system/organ affected. • Identify laterality and or organ component(s) involved. • Review carefully surgical history, and the intended new procedure. • Note any existing device present that may require attention. Gather all the Facts • Evaluate the objective/plan for the root operation - differentiate between body parts and devices. • Examine details to identify the plan as an alteration, bypass, change, creation, removal, replacement, revision, or supplement. • Review carefully the history, physical exam, planned procedure, op report and the pathology report. • Evaluate against the DRG assigned for consistency. Personal History of Congenital Malformation –”Corrected” Z87.7 – Personal history of (corrected) congenital malformations: • If the anomaly has been corrected and is no longer present the code for a personal history should be used- Conditions classifiable to Q00Q89 that have been repaired or corrected. • Excludes1: Congenital malformations that have been partially corrected or repaired but which still require medical treatmentCODE to the condition Personal History of Congenital Malformation –”Corrected” Code Description Z87710 Personal history of (corrected) hypospadias Z87718 Personal history of other specified (corrected) congenital malformations of genitourinary system Z87720 Personal history of (corrected) congenital malformations of eye Z8772 Personal history of (corrected) congenital malformations of ear Z87728 Personal history of other specified (corrected) congenital malformations of nervous system and sense organs Z87730 Personal history of (corrected) cleft lip and palate Z87738 Z8774 Personal history of other specified (corrected) congenital malformations of digestive system Personal history of (corrected) congenital malformations of heart and circulatory system Z8775 Personal history of (corrected) congenital malformations of respiratory system Z8776 Personal history of (corrected) congenital malformations of integument, limbs and musculoskeletal system Z87790 Personal history of (corrected) congenital malformations of face and neck Z87798 Personal history of other (corrected) congenital malformations Review the codes in Chapter 17: Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) Chapter 17 • All Q Codes are found in Chapter 17 of the code book Q00- Q89 • Q codes are assigned to the body system MDC and DRGs for both medical and surgical*Circulatory is one exception that has Congenital Anomaly DRGs for heart • MDC 01 Diseases & Disorders of the Nervous System MDC 02 Diseases & Disorders of the Eye MDC 03 Diseases & Disorders of the Ear, Nose, Mouth & Throat MDC 04 Diseases & Disorders of the Respiratory System MDC 05 Diseases & Disorders of the Circulatory System MDC 06 Diseases & Disorders of the Digestive System MDC 07 Diseases & Disorders of the Hepatobiliary System & Pancreas MDC 08 Diseases & Disorders of the Musculoskeletal System & Connective Tissue MDC 09 Diseases & Disorders of the Skin, Subcutaneous Tissue & Breast MDC 10 Endocrine, Nutritional & Metabolic Diseases & Disorders MDC 11 Diseases & Disorders of the Kidney & Urinary Tract MDC 12 Diseases & Disorders of the Male Reproductive System MDC 13 Diseases & Disorders of the Female Reproductive System MDC 14 Pregnancy, Childbirth & the Puerperium MDC 15 Newborns & Other Meonates with Conditions Originating in Perinatal Period MDC 16 Diseases & Disorders of Blood, Blood Forming Organs, Immunologic Disorders MDC 17 Myeloproliferative Diseases & Disorders, Poorly Differentiated Neoplasms MDC 18 Infectious & Parasitic Diseases, Systemic or Unspecified sites Birth Episode DRGs Are For Babies With Known Congenital Malformations, Deformities And Chromosomal Abnormalities APR-DRGs and MS-DRGs : A Few Designations for Newborn Specific Anomaly DRGs APR-DRGs • 602.1-4 Neonate, Birthwt 1000-1249G W Resp Dist Synd/Oth Major Resp Or Major Anomaly • 607.1-4 Neonate, Bwt 1250-1499G W Resp Dist Synd/Oth Major Resp Or Maj Anomaly • 611.1-4 Neonate, Birthwt 1500-1999G W Major Anomaly • 621.1-4 Neonate, Bwt 2000-2499G W Major Anomaly • 633.1-4 Neonate, Birthwt > 2499g W/ Major Anomaly • 640.1-4 Neonate, Bwt > 2499g, Normal Newborn Or Neonate W Other Problem MS-DRGs • DRG 791 Prematurity with Major Problems • DRG 792 Prematurity without Major problems • DRG 793 Full Term Neonate with Major Problems • DRG 794 Neonate with Other Significant Problems • DRG 795 Normal Newborns • Conditions may be present at all stages of growth and adulthood • Body system DRGs are used after the initial birth DRGs for care MS-DRGs and APR-DRGs: Only a Few Designations for “Medical” Anomaly DRGs APR-DRGs • 095.1-4 Cleft Lip & Palate Repair* (surgical) • 131.1-4 Cystic Fibrosis • 200.1-4 Cardiac Congenital & Valvular Disorders • 662.1-4 Sickle Cell Anemia Crisis Sickle Cell MS-DRG • DRG 306 Cardiac Congenital and Valvular Disorders with MCC • DRG 307 Cardiac Congenital and Valvular Disorders without MCC Body System Specific Medical DRGs • Q codes are assigned to body system DRGs • Example - Microcephaly (Q02 Microcephaly) is assigned to: MS-DRG DRG 091 OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC DRG 092 OTHER DISORDERS OF NERVOUS SYSTEM WITH CC DRG 093 OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC APR-DRG 058 SOI 1-4 Other Disorders of Nervous System MS-DRGs and APR-DRGs for “Medical” Anomaly DRGs Q330 Congenital cystic lung Q331 Accessory lobe of lung Q332 Sequestration of lung Q333 Agenesis of lung Q335 Ectopic tissue in lung Q336 Congenital hypoplasia and dysplasia of lung Q338 Other congenital malformations of lung Q339 Congenital malformation of lung, unspecified Q340 Anomaly of pleura Q341 Congenital cyst of mediastinum Q348 Other specified congenital malformations of respiratory system Q349 Congenital malformation of respiratory system, unspecified Q676 Pectus excavatum Q677 Pectus carinatum Q766 Other congenital malformations of ribs Q767 Congenital malformation of sternum Q768 Other congenital malformations of bony thorax Q769 Congenital malformation of bony thorax, unspecified Q772 Short rib syndrome Q790 Congenital diaphragmatic hernia Q791 Other congenital malformations of diaphragm MS-DRG DRG 205 OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC DRG 206 OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC APR-DRG 143 SOI 1-4 Other respiratory diagnosis except signs, symptoms & minor diagnoses MS-DRGs and APR-DRGs for Cardiac and Circulatory are Very Specific to Condition and/or Procedure MS-DRG APR-DRG DRG 306 CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC 160 SOI 1-4 Major Cardiothoracic Repair of Heart Anomaly DRG 307 CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC 161 SOI 1-4 Cardiac Defibrillator & Heart Assist Anomaly 200 SOI 1-4 Cardiac Congenital & Valvular Disorders Cardiac Congenital and Valvular Disorders Q200 Q201 Q202 Q203 Q204 Q205 Q206 Q208 Common arterial trunk Double outlet right ventricle Double outlet left ventricle Discordant ventriculoarterial connection Double inlet ventricle Discordant atrioventricular connection Isomerism of atrial appendages MS-DRG DRG 306 CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC DRG 307 CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC Other congenital malformations of cardiac chambers and connections Q209 Congenital malformation of cardiac chambers and connections, unspecified Q210 Q211 Q212 Q213 Q214 Q218 Ventricular septal defect Atrial septal defect Atrioventricular septal defect Tetralogy of Fallot Aortopulmonary septal defect Other congenital malformations of cardiac septa Q219 Congenital malformation of cardiac septum, unspecified Pulmonary valve atresia Congenital pulmonary valve stenosis Congenital pulmonary valve insufficiency 160 SOI 1-4 Major Cardiothoracic Repair of Heart Anomaly Other congenital malformations of pulmonary valve Congenital tricuspid stenosis Ebstein's anomaly Hypoplastic right heart syndrome Other congenital malformations of tricuspid valve 161 SOI 1-4 Cardiac Defibrillator & Heart Assist Anomaly 200 SOI 1-4 Cardiac Congenital & Valvular Disorders Q220 Q221 Q222 Q223 Q224 Q225 Q226 Q228 Q229 Q230 Q231 Q232 Q233 Q234 Congenital malformation of tricuspid valve, unspecified Congenital stenosis of aortic valve Congenital insufficiency of aortic valve Congenital mitral stenosis Congenital mitral insufficiency Hypoplastic left heart syndrome APR-DRG Cardiac Congenital and Valvular Disorders Q238 Q239 Other congenital malformations of aortic and mitral valves Q240 Q241 Q242 Q243 Q244 Q245 Q248 Q249 Q250 Q251 Q252 Q253 Q254 Q255 Q256 Q2571 Q2572 Q2579 Q258 Q259 Q260 Q261 Q262 Q263 Q264 Q268 Q269 Q8740 Q87410 Dextrocardia Levocardia Cor triatriatum Pulmonary infundibular stenosis Congenital subaortic stenosis Malformation of coronary vessels Other specified congenital malformations of heart Congenital malformation of heart, unspecified Patent ductus arteriosus Coarctation of aorta Atresia of aorta Supravalvular aortic stenosis Other congenital malformations of aorta Atresia of pulmonary artery Stenosis of pulmonary artery Coarctation of pulmonary artery Congenital pulmonary arteriovenous malformation Other congenital malformations of pulmonary artery Other congenital malformations of other great arteries Congenital malformation of great arteries, unspecified Congenital stenosis of vena cava Persistent left superior vena cava Total anomalous pulmonary venous connection Partial anomalous pulmonary venous connection Anomalous pulmonary venous connection, unspecified Other congenital malformations of great veins Congenital malformation of great vein, unspecified Marfan's syndrome, unspecified Q87418 Congenital malformation of aortic and mitral valves, unspecified Marfan's syndrome with aortic dilation Marfan's syndrome with other cardiovascular manifestations MS-DRG DRG 306 CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC DRG 307 CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC APR-DRG 160 SOI 1-4 Major Cardiothoracic Repair of Heart Anomaly 161 SOI 1-4 Cardiac Defibrillator & Heart Assist Anomaly 200 SOI 1-4 Cardiac Congenital & Valvular Disorders Official Coding Guideline • C.1.17 Assign codes from category Q00 – Q99, congenital malformations, deformations, and chromosomal abnormalities when a malformation/deformation or chromosomal abnormality is documented. Q codes may be the principal/first – listed diagnoses on a record or a secondary diagnoses. When a malfor/deform or chromosomal abnormality does not have a unique code assignment, assign additional code(s) for any manifestations that may be present. When the code assignment specifically identifies the malfor/deform/or chromosomal abnormality, manifestations that are an inherent component of the anomaly should not be coded separately. Additional code should be assigned for manifestations that are not in inherent component. Official Coding Guideline Codes from Chapter 17 may be used throughout the life of the patient. If a congenital malformation or deformity has been corrected, a personal history code should be used to identify the history of the malformation or deformity. (code the condition until it is corrected) Although present at birth, malformation/deformation/or chromosomal abnormality may not be identified until later in life. When ever the condition is diagnosed by the physician, is appropriate to assign a code from codes Q00 – Q99. The condition is coded until it is completely corrected PCS Characters 24 Root operation and approach are key indicators of the OR impact for surgical DRGs PCS Characters Determine Minor or Major Procedure for Both MS and APR DRGs • Root operations (3) • Approach (5) Bypass, alteration, change, creation, removal, replacement, revision, or supplement Open Percutaneous Endoscopic Percutaneous Body Part & Device Characters Determine Some MSDRGs and APR-DRGs Body part (4) Major organs and other major anatomical structures − Lungs- Bronchus − Heart- Valves − Brain- Ventricles Other tissue − Pericardium DRG Examples – Major Chest Procedure Other Respiratory System Procedures Cardiac Valve and Other Major Cardiothoracic Procedures Other Cardiothoracic Procedures Device (6) Autologous Non-autologous Synthetic Zooplastic Defibrillator-cardiac assist DRG Examples – Cardiac Defibrillator & Heart Assist Anomaly Ventricular Shunt Procedures 27 Utilize All Sources and Documents PCS Coding Support Documents − Pre –procedure history of the condition and previous procedures(episode of care) − Informed consent and documented indication for the procedure − Anesthesia pre and post evaluation − Operative/procedure report − Brief operative/procedure progress note − Pre and post Imaging, fluoroscopy and other radiology/procedure reports − Device and equipment inventory list for the surgical case − Pathology report –cytology report Newborn Surgical DRGs • Congenital conditions identified and coded at birth will generate a newborn DRG • MS-DRGs are determined first by prematurity/full term status and then by the severity and number of anomalies coded – MS-DRGs do not provide a surgical DRG for any procedure performed • APR-DRGs are assigned first by birthweight, major, minor or multiple anomalies and major cardiovascular or other major procedures MS-DRG DRG 791 PREMATURITY WITH MAJOR PROBLEMS DRG 792 PREMATURITY WITHOUT MAJOR PROBLEM DRG 793 FULL TERM NEONATE WITH MAJOR PROBLEMS MS-DRGs do not provide any surgical options APR-DRG 588 SOI 1-4 Neonate BWT <1500G W Major Procedure 609 SOI 1-4 Neonate, BWT 1500-2499G W Major Procedure 630 SOI 1-4 Neonate, Birthwt > 2499g w/ Major Cardiovasc Procedure Surgical DRGs • Depending on the procedure performed the surgical DRG for minor, major, or other procedure will be assigned. • Example DRG: Colostomy creation (bypass)- 0D1B0Z4 for bowel obstruction (ileum) due to congenital prune belly syndrome Q794, with imperforate anus Q422 is assigned to DRGs: MS-DRG APR-DRG DRG 329 DRG 330 DRG 331 MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 221 SOI 1-4 MAJOR SMALL AND LARGE BOWEL PROCEDURES Surgical DRGs • Depending on the procedure performed the surgical DRG for minor, major, or other procedure will be assigned. • Example DRG- Open destruction of ileum mass/nodule- 0D5B0ZZ, for bowel obstruction due to congenital prune belly syndrome Q794, with imperforate anus Q422 is assigned to DRGs: MS-DRG APR-DRG DRG 344 DRG 345 DRG 346 MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC MINOR SMALL AND LARGE BOWEL PROCEDURES Without CC/MCC 223 SOI 1-4 OTHER SMALL AND LARGE BOWEL PROCEDURES Surgical DRGs • Depending on the procedure performed the surgical DRG for minor, major, or other will be assigned. • Example DRG- Open repair right thumb 0PQR0ZZ- as part of reconstruction staged for Ectrodactyl Q7161 (lobster claw anomaly) of right hand assigned to DRGs: MS-DRG APR-DRG DRG 515 OTHER MUSCULOSKELETAL & CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC DRG 516 OTHER MUSCULOSKELETAL & CONNECTIVE TISSUE O.R. PROCEDURES WITH CC DRG 517 OTHER MUSCULOSKELETAL & CONNECTIVE TISSUE O.R. 320 SOI 1-4 Other Musculoskeletal & Connective Tissue Procedures Some APR-DRGs are Anomaly/Anatomy Specific Repairs • 095.1-4 Cleft Lip & Palate Repair • 160.1-4 Major Cardiothoracic Repair of Heart Anomaly Many surgeries and corrections will be performed shortly after birth in the same encounter for birth. Other surgeries may be spaced out over a span of months or years, and involve different objectives to achieve correction or cosmetic improvement. Surgical DRGs • Depending on the procedure performed the surgical DRG may include anatomy specific repairs/corrections. • Example DRG- Placement of ventriculo-peritoneal shunt – 0016076, for congenital hydrocephaly (Q039 Congenital hydrocephalus, unspecified). MS-DRG APR-DRG DRG 031 VENTRICULAR SHUNT PROCEDURES WITH MCC DRG 032 VENTRICULAR SHUNT PROCEDURES WITH CC DRG 033 VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC 022 SOI 1-4 VENTRICULAR SHUNT PROCEDURES Surgical DRGs • Depending on the procedure performed the surgical DRG may include anatomy specific repairs/corrections. • Example DRG - Supplement of hard palate with autologous tissue open approach - 0CU207Z for congenital cleft hard and soft palate with bilateral cleft lip – Q374 MS-DRG DRG 133 OTHER EAR, NOSE MOUTH, AND THROAT PROCEDURES WITH CC/MCC DRG 134 OTHER EAR, NOSE MOUTH, AND THROAT PROCEDURES WITHOUT CC/MCC APR-DRG 095 SOI 1-4 Cleft Lip & Palate Repair | 35 Surgical DRGs - Episode of Care Impact • Example APR-DRG – 1 day old newborn- Z3800 with Congenital Hypertrophic Pyloric Stenosis Q400Division of pyloric stenosis 0D870ZZ • APR-DRG 639 SOI 1-4 Neonate birthwt >2499g w other significant condition • Example APR-DRG – 8 day old newborn readmitted with Congenital Hypertrophic Pyloric Stenosis Q400Division of pyloric stenosis 0D870ZZ APR-DRG 222 SOI 1-4 Other Stomach, Esophageal, Duodenal procedure Other Congenital Diagnoses are Located in the Body System Specific APR-DRGs Other conditions/manifestations have anomaly specific medical DRGs • 662.1-4 Sickle Cell Anemia Crisis Sickle cell • 131.1-4 Cystic Fibrosis • 200.1-4 Cardiac Congenital & Valvular Disorders DRG Categories to Remember Birth Episode DRGs MS-DRGs – no surgical options APR-DRGs Include weight, anomaly(s) and surgery Post Birth -Medical DRGs Primarily body system specific Few congenital specific DRGs Surgical DRGs Anatomy/repair specific for major or minor, or other procedures Few are congenital specific DRGs Coding Rule Code the condition until corrected May be principal or secondary Once corrected code to personal history Key Take Away Points 1. Identify the episode of care 2. Determine if the diagnosis/condition is currently requiring care, or is only a personal history of a past diagnosis with the condition “corrected” 3. Do not code procedures without the operative report, procedure report or the pathology report 4. Be ready to interpret your anatomy, surgical and device terminology 5. Differentiate the root operations used: bypass, alteration, change, creation, removal, replacement, revision, or supplements Key Take Away Points 6. Determine if a device will be used and what type 7. Seek to code to the exact location of the targeted anatomical structure and the surrounding tissue(s) that is specified 8. Utilize all the documentation available for code selection and decision making such as imaging and radiology reports 9. Read the final DRG description carefully and evaluate it against the objective and diagnosis the patient is treated for to be sure it is consistent with codes used for the procedures 10. Query if the information is not clear or is not consistent References 40 http://www.cms.gov/icd10manual/version33.0-fullcode-cms/P00124.html http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-PCSguidelines.pdf https://www.health.ny.gov/facilities/hospital/reimbursement/apr-drg/weights/ ICD-10-PCS Official Guidelines for Coding and Reporting 2016 OptumCoding [email protected] | 42 You are invited to stay for a short overview on Elsevier’s education solutions for Clinical Documentation Improvement ElsevierRevenueCycle.com | 43 Elsevier Revenue Cycle Solutions Elsevier is proud to be a leader for online professional education. As the education solution for thousands of hospitals and millions of users Elsevier keeps abreast of industry needs to offer focused, pertinent, and timely education that can be packaged for unique organizational needs. | 44 We Provide CDI Education and Tools for: Physicians and non-physician providers Coders, CDI professionals and administrative/billing staff Nurses | 45 Our CDI and Coding Education Covers: 36 CE-approved lessons for providers and CDI professionals on documentation by place and type of service; regulatory and guideline-driven requirements; and documentation education on 24 individual diagnosis and procedure topics spanning health sciences, comorbidities, clinical indicators, treatments, and quality or payment information Coding and CDI Competency Tools –unique validated exams, based on job analysis, and covering major domains associated with CDI, inpatient coding and outpatient coding job role requirements 52 physician lessons, by unique topic, plus awareness education for ICD-10-CM/PCS, offering CME 343 inpatient and outpatient ICD-10-CM/PCS and CPT coding lessons by specialties and specific topics with pre-approved CE | 46 Lessons specific to Congenital Anomalies Doc Briefs Coding • Pediatric Congenital Cardiac Anomalies • Pediatric Congenital Digestive Anomalies • Introduction: Lesson 14: Complications, Comorbidities, and the Present On Admission (POA) Indicator • Disorders of the Thyroid Gland • Family Practice, Pediatric, Internal Medicine Services • ICD-10-CM/PCS Perinatal Conditions and Congenital Anomalies • Overview • Congenital Anomalies of Nervous, Circulatory, or Respiratory System • Perinatal Procedures • Congenital Anomaly Repairs and Associated Procedures • Congenital Anomalies of Digestive, Genitourinary, and Musculoskeletal Systems • Conditions Originating in the Perinatal Period | 47 Take a Look at Our Lessons Interested in learning more? 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