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DRG Impact
DRG Partition
Procedures fall into 3
categories:
a. Non-OR procedures, not
affecting MS-DRG.
b. Non-OR procedures
affecting MS-DRG
assignment.
c. Valid OR procedures.
Highest DRGs
•
Major Comorbidity & Complication (MCC) Versus Comorbidity &
Complication (CC)
•
Present On Admission Indicators (POA) & Hospital Acquired Conditions
(HACs)
•
Medical Versus Surgical Partition
•
Procedures affecting DRG selection.
•
CC Exclusions.
MS-DRG / MCCs & CCs / Principal Diagnosis
Patient admitted with a principal diagnosis of third degree scalp laceration. Which one of these procedures will affect
the MS-DRG selection?
A. Percutaneous drainage of right hand muscle.
B. Transfer of skin, scalp, external
C. Percutaneous dilation of right ureter with intraluminal device
D. Control of epistaxis via natural opening.
A.
B.
C.
D.
0K9C322 (Non-OR Procedure, does not affect DRG)
0HX0XZZ (Valid OR procedure, does affect DRG)
0T763DZ (Non-OR Procedure, does not affect DRG)
093K7ZZ (Non-OR Procedure, does not affect DRG)
Check the PCS Coding tables in the coding book for details to identify Non-OR versus OR procedures. There are symbols
at the bottom of each page
Some codes vary based on the 4th to 7th characters
MS-DRG / MCCs & CCs / Principal Diagnosis
Patient is diagnosed with spondylolisthesis of the cervical region. Which one of these
will increase the MS-DRG for this patient if present on admission?
A. Primary hypotony of left eye.
B. Underdosing of other drugs acting on muscles.
C. Chronic respiratory disease.
D. Hereditary factor IX deficiency.
D. Hereditary factor IX deficiency, since this is an MCC.
MS-DRG / MCCs & CCs / Principal Diagnosis
Which of the following will impact the DRG selection if present on admission?
If the patient has a diagnosis of septicemia, which of the following procedures will increase the MS-DRG
assignment the most?
A)
Bronchoscopy with left bronchus biopsy (0BB74ZX)
B)
Debridement of toenail (OHBRXZZ)
C)
Nonexcisional debridement of skin ulcer of perineum with abrasion (OHD9XZZ)
D)
Respiratory ventilation. Greater than 96 consecutive hours
D) The ventilator management is the procedure that will affect the MS-DRG to provide appropriate
reimbursement. The MS-DRG with the highest weight is 870.
MS-DRG / MCCs & CCs / Principal Diagnosis
A female patient is diagnosed with congestive heart failure. Which of the following will
increase the MS-DRG weight if present on admission?
A) Atrial fibrillation
B) Stage III pressure ulcer
C) Blood loss anemia
D) Coronary artery disease
B) MS-DRG 291 (weight=01.5174) for CHF with stage III pressure ulcer would optimize
the MS-DRG. MS-DRG 293 (weight = 00.6751) is assigned for CHF alone, with atrial
fibrillation, with blood loss anemia, and with coronary disease all remain the same
MS-DRG / MCCs & CCs / Principal Diagnosis
If the principal diagnosis is an initial episode of an anterior wall myocardial infarction, which
procedure will result in the highest DRG?
A) Mechanical ventilator
B) Insertion central venous catheter
C) Right heart cardiac catheterization
D) Trans bronchial lung biopsy
D) MS-DRG 264 (weight = 02.6674) for MI with transbronchial lung biopsy would result in the
highest reimbursement.
MS-DRG 282 (weight = 00.7736) would be assigned for MI alone, and with insertion central
venous catheter.
MS-DRG 282 (weight= 00.77360) would be assigned for MI with mechanical ventilator.
Principal Diagnosis
A patient is admitted with spotting and fever. She is found to have been treated or a miscarriage (spontaneous
abortion), which was resolved two weeks prior to this admission. She is treated with aspiration dilation and
curettage and products of conception are found. She is found to be septic. Which of the following diagnoses
should be principal diagnosis?
A) Complications following abortion and ectopic or other pregnancy
B) Complications of spontaneous abortion with sepsis
C) Sepsis
D) Sepsis following incomplete spontaneous abortion
D) The patient was previously treated for spontaneous abortion but the presence of the products of conception
denotes that the abortion was not completed during the prior episode of care. Because of this and the fact that
she now has sepsis, this is coded as sepsis following an incomplete spontaneous abortion.
Principal Diagnosis
A patient is admitted to a healthcare facility with ataxia and syncope. The patient has a history of lung cancer.
The patient also has a fractured arm as a result of falling. The patient undergoes a closed reduction of the
fracture in the emergency department and a complete workup for metastatic carcinoma of the brain. The
patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the
brain. The principal diagnosis should be:
A) Fracture arm
B) Syncope
C) Metastatic carcinoma of the brain
D) Carcinoma of the lung
C) According the UHDDS definition of principal diagnosis is "that condition established after study to be chiefly
responsible for occasioning the admission of the patient to the hospital for care". In this case, metastatic
carcinoma of the brain is responsible for the patient's fall, ataxia and syncope
Principal Diagnosis
A 78-year-old patient is admitted with shortness of breath and a chest X-ray reveal infiltrates in the lung with
pleural effusion. The patient also has a history of hypertension with left ventricular hypertrophy. The patient is
given Lasix and the shortness of breath is relieved. From the information given, what is the probable principal
diagnosis?
A) Pneumonia
B) Congestive heart failure
C) Pleural effusion
D) COPD
B) Congestive heart failure
Principal Diagnosis
A patient is admitted with abdominal pain. The discharge documentation states "pancreatitis vs noncalculus
cholecystitis" as the final diagnosis. Both diagnoses are equally treated. Based on coding guidelines, what is the
correct sequencing for these diagnoses?
A) Sequence either the pancreatitis or noncalculus cholecystitis first
B) Pancreatitis; noncalculus cholecystitis; abdominal pain
C) Noncalculus cholecystitis; pancreatitis
D) Sequence the abdominal pain first, followed by the pancreatitis and noncalculus cholecystitis as secondary
diagnosis
A) Sequence either the pancreatitis or noncalculus cholecystitis first
Principal Diagnosis
A patient is admitted as an inpatient and discharged with chest pain. After evaluation, it is suspected the
patient may have gastro-esophageal reflux disease (GERD). The final diagnosis was "Rule out GERD". The
correct code assignment would be:
A) Z03.9, Encounter for observation for other suspected diseases and conditions ruled out
B) R10.11, Right upper quadrant pain
C) K21.9, Gastro-esophageal reflux disease without esophagitis
D) R07.9, Chest pain; unspecified
C) In the inpatient setting, "Rule Out" diagnoses are coded as if they exist. In this case the patient has chest
pain and the reason for the chest pain is rule out GERD. This requires that the GERD be coded as the first listed
diagnosis
MS-DRG / MCCs & CCs / Principal Diagnosis
A patient is admitted with an acute inferior myocardial infarction and discharged alive. Which condition would
increase the MS-DRG weight?
A) Respiratory failure
B) Atrial fibrillation
C) Hypertension
D) History of myocardial infarction
A) MS-DRG 280(weight = 01.7999) for myocardial infarction with respiratory failure would change the MS-DRG.
MS-DRG 282 (weight = 00.7736) would be assigned for myocardial infarction alone, with atrial fibrillation, with
hypertension, and with history of myocardial infarction
CC Exclusion List
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•
•
This list contains code pairs that are not going to affect DRGs same way together as they would if they were coded
separately.
CC Exclusion list is available in the ICD 10 CM coding book
List of diagnosis codes that behave as a CC or MCC if the patient is discharged alive.
Patient was admitted with coma and expired at the time of discharge. Which of these conditions will affect the DRG assignment?
A. Amebic cystitis
B. Thalassemia Minor
C. Respiratory arrest
D. Cardiomegaly
Amebic cystitis – A06.81 is a CC
Thalassemia Minor – D56.3 – not a CC
Respiratory arrest – R09.2 – this is an MCC but is not on the CC exclusion list and patient expired
Cardiomegaly – I51.7 – is not a CC
R09.2 is considered an MCC only if the patient is discharged alive. This patient has expired, so the correct answer would be
Amebic cystitis since this is a CC
Thank You