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IPPS Changes FY 2008
Presenter
Mary D. Gregory, RHIT, CCS, CPC,
CCS-P
September 18,2006
www.mascoding.com
Disclaimer
 MAS (Medical Administrative Solutions) makes no representation or
guarantee with respect to the contents here and specifically disclaims any
implied guarantee of suitability for any specific purpose.
 MAS has no liability or responsibility to any person or entity with respect to
any loss or damage caused by the use of the workshop material, including but
not limited to any loss of revenue, interruption of service, loss of business or
indirect damage resulting from the use of this information.
• This is current as of August 22,2007.
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This is an abbreviated portion of the presentation that was given on the
above date.
As we well know there has not been a major overhaul of the IPPS DRGs
for twenty years. I am confident that coders will rise to the challenge of
coding and assign the most appropriate MS-DRG. I hope that
you find this information informative and useful.
Mary D. Gregory, RHIT, CCS, CPC, CCS-P
License PMCC Instructor
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Important Index changes for 2008
Cerebrovascular Accident/Infarction/Reversible Ischemic Neurological Deficit
(RIND) Or Prolonged Reversible Ischemic Neurological Deficit
Aborted
434.91
Deficit (ischemic reversible
(RIND)
434.91
Deficit (prolonged (PRIND)
434.91
Postoperative Anemia due
to (acute) blood
285.1
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Achieving Documentation Improvement
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CC Revisions
CMS reviewed 13,549 ICD-9-CM codes to evaluate their
assignment as a CC or non-CC.
Diagnoses included as CC if they met the following criteria:
• Intensive monitoring (for example, an ICU stay)
• Expensive and technically complex services
• Extensive care requiring a greater number of caregivers (for example
nursing care for a quadriplegic)
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CC Revision:
 Chronic diagnoses having a broad range of manifestations
are not assigned to the CC list as long as there are codes
available that allow the acute manifestations of the disease
to be coded separately.
 Non specific codes were deleted from the CC List.
Physician must be encouraged to document as specific as
possible.
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Deleted CC:
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Stable angina
COPD
Congestive heart failure
Dehydration
Drug Abuse
Ulceration of lower extremity
Hypoxia
Atrial fibrillation
Chronic renal failure
Seizure disorder
Chronic blood loss anemia
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Examples of CC:
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Acute Blood loss anemia
Acute exacerbation of COPD
Jaundice, unspecified, not of newborn
Aphasia
Precipitous drop in hematocrit
Attention to gastrostomy
Suicidal ideation
Hemorrhage complicating a procedure
Unstable angina
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Examples of Major CC (MCC)
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Acute respiratory failure
Encephalopathy
Pulmonary embolism and infarction
Sepsis
Acute renal failure
Acute systolic/diastolic heart failure
Myocardial Infarction
Pneumonia
Pleurisy with effusion
Aspiration Pneumonia
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Will not count as MCC or CC if the patient expires.
427.41
427.5
785.51
785.59
799.1
Ventricular fibrillation
Cardiac arrest
Cardiogenic shock
Other shock
Respiratory arrest
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MS-DRGs CC
Number of MS DRGs 745
Breakdown of Codes
MCC
1096
CC
4221
Non-CC
8232
Total
13549
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Number of CC Subgroups
Subgroups
#of Proposed Base MS-DRGs
# of Proposed MS-DRGs
No Subgroup
53
53
Three subgroups-MCC/CC/Non CC
152
456
Two subgroups with CC/MCC and
without CC/MCC
43
86
Two Subgroups with MCC and
without MCC
63
126
MDC 14
22
22
Error DRGs
2
2
335
745
Total
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MS DRG with 3 Subgroups
DRG
Weight
Payment
079 (CMS DRGs)
Resp Infection/CC
1.6262
$8168
080 (CMS DRGs)
Resp Infection wo/cc
0.8949
$4495
177 (MS DRGs)
Resp Infection/MCC
2.018
$10136 (+1968)
178 (MSDRGs)
Resp Infection /cc
1.5058
$7560
(-608)
179 (MS DRGs)
Resp Infection wo/cc
1.0484
$5266
(+771)
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MS DRG with 2 Subgroups with MCC and Without MCC
DRG
Description
Weights
Payment
078 (CMS DRGs)
Pulmonary Embolus
1.2364
$6210
175 (MSDRGs)
Pulmonary Embolus
with MCC
1.6160
$8117 (+1907)
176 (MSDRGs0
Pulmonary Embolus
without MCC
1.0969
$5509 (-701)
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MS DRGs with 2 Subgroups with CC/MCC and without CC/MCC
DRG
Description
Weight
Payment
021 (CMS DRGs)
Viral Meningitis
1.4131
$7065
075 (MS DRGs)
Viral Meningitis
w/CC/MCC
1.7156
$8578 (+$1513)
076 (MS DRGs)
Viral Meningitis w/o
CC/MCC
0.9367
$4683 (-$2382)
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Examples of Current CMS DRGs Versus MS-DRGs
Hip& Femur Procedures except major joint with CC
CMS DRGs 210 with
CC
CMS DRGs 482 w/o
CC/MCC
CMS DRGs 480
w/MCC
CMS DRG 481 w/CC
PDx: Fx Hip
PDx: Fx Hip
PDx: Fx Hip
PDx: Fx Hip
SDx: CHF
Emphysema
Hypoxia
PPx: ORIF
SDx: CHF
Emphysema
Hypoxia
PPx: ORIF
SDx: Acute systolic
heart failure
Emphysema
Hypoxia
PPx: ORIF
SDx: Chronic systolic
heart failure
Hypoxia
COPD
PPx: ORIF
WT: 1.9021
$ 9510
WT: 1.4721
$ 7360 (-$2150)
WT: 2.8506
$ 14253 (+4743)
WT: 1.8267
$ 9133 (-$377)
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Definition of Principal Diagnosis:
The condition established after study to be chiefly responsible
for admission of the patient to the hospital.
The words “after study” in the definition of principal diagnosis
are important, but they are sometimes confusing. It is not
the admitting diagnosis but rather the diagnosis found after
workup or even after surgery that proves to be the reason for
admission.
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The circumstances of inpatient admission always govern the
selection of the principal diagnosis, and the coding directives
in the ICD-9-CM manuals, volumes 1,2,and 3, take precedence
over all other guidelines.
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Rules Governing the Selection of Principal Diagnosis:
Two or more diagnoses that equally meet the definition for
principal diagnosis.
In the unusual situation in which two or more diagnoses equally meet the
criteria for principal diagnosis as determined by the circumstances of the
admission and the diagnostic workup and/or therapy provided ,either may
be sequenced first when neither the Alphabetic Index nor the Tabular List
directs otherwise.
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When treatment is totally or primarily directed toward one
condition, or when only one condition would have required
inpatient care, that condition should be designated as the
principal diagnosis. Also, if another, coding guidelines
(general or disease-specific) provides sequencing direction,
that guideline must be followed.
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Two or more comparable or contrasting conditions:
In the rare cases where two or more comparable or contrasting
conditions are documented as either/or (or similar terminology),
both diagnoses are coded as though confirmed and the principal
diagnosis is designated according to the circumstances of the
admission.
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Symptom followed by contrasting/comparative diagnoses:
When a symptom is followed by contrasting/comparative diagnosis, the
symptom code is sequenced first unless it is integral to each of the
condition listed. Codes are assigned for all listed contrasting/
comparative diagnoses.
Inpatient Reporting Guideline:
Questionable, suspected, to be ruled out diagnosis are coded as if the
condition exist if the physician does not states or the record does not
explicitly implies that the condition was ruled out.
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Original Treatment Plan not carried out:
In a situation in which the original treatment plan cannot be carried out due to
unforeseen circumstances, the criteria for designation of the principal diagnosis
do not change. The condition that occasioned the admission is designated as
principal diagnosis even though the planned treatment was not carried out.
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Other Diagnoses (secondary diagnoses) :
Other reportable diagnoses are defined as those conditions that
coexist at the time of admission or develop subsequently or affect
patient care for the current hospital episode. Diagnoses that have
no impact on patient care during the hospital stay are not reported
when they are present. Diagnoses that relates to an earlier episode
and have no bearing on the current hospital stay are not reported
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For UHDDS reporting purposes, the definition of “other” includes
only those conditions that affect the episode of hospital care in terms
of any of the following:
 Clinical evaluation
 Therapeutic treatment
 Further evaluation by diagnostic studies, procedures, or consultation
 Extended length of hospital stay
 Increased nursing care and/or other monitoring
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Inpatient Reporting Guidelines:
All physician documentation can be used in the coding process.
However, coders must be aware that there cannot be any conflicting
information between the attending physician and the other physicians
documenting in the medical record.
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Physician Documentation:
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History and Physical
Progress notes
Consultation Reports
Emergency Department
Discharge Summary
Anesthesiologist H&P or consultation notes
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Documentation that coders cannot code from and will need further
physician input:
• Orders
• Abnormal labs
• Abnormal radiological reports
• Pathological findings
• EKGs/ Other Cardiovascular tools (i.e. echo)
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Diagnoses not listed in the final diagnostic statement:
Per the AHIMA Practice Brief on Data Quality the coding professional
may “assign and report codes, without physician consultation, to
diagnoses and procedures not stated in the physician’s final diagnosis
only if these diagnoses and procedures are specifically documented by
the physician in the body of the medical record and this document is
clear and consistent.”
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When the documentation in the medical record is clear and consistent,
coders may assign and report codes. If there is evidence of a diagnosis
within the medical record, and the coder is uncertain whether it is a
valid diagnosis because the documentation is incomplete, vague, or
contradictory, it is the coder’s responsibility to query the attending
physician to determine if the diagnosis should be included in the
final diagnostic statement.
All diagnoses should be supported by physician documentation.
Documentation is not limited to the face sheet, discharge summary,
progress notes, history and physical, or other reports designed to
capture diagnostic information. (CC 2nd Quarter 2000)
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Documentation from non-attending physician
Code assignment may be based on other physician (i.e. consultants,
residents, anesthesiologist, etc.) documentation as long as there is no
conflicting information from the attending physician. Medical record
documentation from any physician involved in the case and treatment
of the patient including consulting physicians can be coded as long as
there is no conflicting information from another physician.
If documentation conflict you must seek clarity from the attending
physician, as the attending physician is ultimately responsible for the
final diagnosis. (CC 1st Quarter 2004)
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Documentation by mid-level providers
It is appropriate to use the health record documentation of other
providers, such as nurses practitioners, and physician assistants as the
basis for code assignment to report new diagnoses, if they are
considered legally accountable for establishing a diagnosis within the
regulations governing the provider and the facility. The Official
Guidelines for Coding and Reporting define a provider as the
individual legally accountable for establishing a diagnosis.
(CC 4th Quarter 2004)
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Coding from diagnostic tests:
For inpatient coding, if the attending physician does not confirm the
pathological findings, radiologist findings or laboratory findings
the attending physician must be queried regarding the clinical
significance of the findings.
(CC 2nd Quarter 2002)
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Documentation that will require clarity (frequent flyers)
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See past history
Will not repeat history see previous record
Patient well known to me
Conflicting information between the mid-level provider and the physician
Per coding guidelines each encounter must stand on it own.
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Diagnostic Statements that affect Code Selections
Good/Fair Documentation
Better Documentation
Morbid Obesity, Massive Obesity, Obesity
BMI over 40 , adult or the specific BMI
that applies to the patient
Depression
Bipolar Disorder, Major Depressive
Disorder, Suicidal ideation
Cocaine use, history of cocaine (patient
use last night) UDS positive for cocaine,
barbiturates, or opioid etc
The specific drug dependence and the
use pattern. (fifth digit of .1 is the only
one that is a CC)
Underweight or very thin patient
BMI of less than 19, adult
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Diagnostic Statements that affect Code Selections
Good/Fair Documentation
Better Documentation
Seizure disorder
Epilepsy with intractable seizure
Hypertension uncontrolled
Accelerated/malignant hypertension and
the specific type such as cardiovascular
and/or hypertensive
Unstable chest pain or angina
Unstable angina, coronary insufficiency
acute or subacute
Pulmonary hypertension
Primary pulmonary hypertension
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Diagnostic Statements that affect Code Selections
Good/Fair Documentation
Better Documentation
Cervical spondylosis, lumbar spondylosis,
thoracic spondylosis
Cervical spondylosis, lumbar spondylosis,
thoracic spondylosis with myelopathy
Drop in hematocrit
Precipitous drop in hematocrit
Dehydration
Hyponatremia
Acute renal insufficiency
Acute renal failure
Difficulty voiding
Urinary retention
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Diagnostic Statements that affect Code Selections
Good/Fair Documentation
Better Documentation
Acute exacerbation of Pulmonary fibrosis
Respiratory failure, pneumonia, passive
congestion, chronic congestion
Sputum cultures positive for staph, strep,
pseudomonas etc
Bacterial pneumonia such as staph,
pseudomonas, strep etc
Hypoalbuminemia, low T-protein
Malnutrition ,severe protein calorie severe
Skin ulceration
Decubitus ulcer of the specific site
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Diagnostic Statements that affect Code Selections
Good/Fair Documentation
Better Documentation
Atrial fibrillation
Atrial flutter
Congestive heart failure
Systolic or Diastolic heart failure or a
combination- acute or chronic or acute
superimposed on chronic
Left side weakness due to old CVA or left
side paresis due to old CVA, weakness
lower extremities due to old CVA
Hemiplegia, or paralysis left or right side
COPD
Acute exacerbation of COPD
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