2. Inpatient Prospective Payment System Flashcards
When did Medicare begin reimbursement based on actual charges?
1965
When did Medicare begin using a fixed payment system?
1983
Who created the DRG system?
Robert Barclay Fetter and John Devereaux Thompson at Yale University
When did Medicare adjust the DRG for severity with the creation oft the Medicare Severity (MS) DRG?
2007
What was the intention of the DRG?
Patient classification system that relates types of patients treated to the expected resources they consume
How does a DRG work?
The hospital receives ONE payment based on the principle diagnosis, procedures performed and certain secondary diagnoses. This payment must cover all services provided during an encounter.
What is the CMS DRG Definitions Manual?
The document that contains the history, design and classification rules of the DRG system, as well as its application to patient discharge data
How are DRGs assigned?
DRGs are assigned by a grouper software program based on ICD diagnoses, procedures, age, sex, discharge status and the presence of complications and comorbidities
When does CMS publish annual updates/changes in the Federal Register? When are updates effective?
August 1 & October 1
What is the purpose of a severity-adjusted DRG?
To quantify differences in demographic and clinical risk factors among patients and to compare clinical outcomes (mortality/complications) and utilization measures (LOS, cost)
SOI
Severity of Illness. The extent of physiologic decompensation or organ system loss of function.
How sick is the patient.
ROM
Risk of Mortality. The likelihood of dying
Resource Intensity
The relative amount and type of diagnostic, therapeutic and bed services used in management of a particular disease
What are the four subclasses of SOI and ROM?
1-minor, 2-moderate, 3-major and 4-extreme
MMME
What are the 6 factors that determine DRG assignment?
Principle diagnosis, procedures performed, specific secondary diagnoses, age, sex and discharge disposition
What is the PDX?
Patient is admitted w worsening cough and SOB x3d. Pulse ox 88% on RA, placed on 2L O2 via NC. Started on IV abx. CXR reveals sm. infiltrate. Pneumonia. LOS 2 days. d/c with abx
Pneumonia ICD-9-CM 486
Simple Pneumonia and Pleurisy DRGs 193-195
What is the PDX?
Patient is admitted with acute exacerbation of CHF and Pneumonia. Admit to ICU. admin IV diuretic and IV abx.
Either can be sequenced as PDX.
Which diagnosis consumed the most resources?
Required the most M.E.A.T.
PDX Rule #1
When two or more diagnoses equally meet the criteria for principal diagnosis EITHER of the diagnoses may be sequenced first.
PDX Rule #2
When there are two or more INTERRELATED conditions (such as diseases in the same ICD chapter or manifestations characteristically associated with a certain disease) that are treated equally and both meet the definition of principal diagnosis, EITHER condition may be sequenced first
PDX Rule #3
If the diagnosis documented at the time of discharge* is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” “still to be ruled out,” or other similar terms indicating uncertainty, code the condition as if it existed or was established.
Example: “RLL pneumonia possibly due to aspiration.” Code aspiration pneumonia.
PDX Rule #4
Codes for symptoms, signs, and ill-defined conditions from Chapter 16 in ICD-9-CM cannot be used as principal diagnosis when a related definitive diagnosis has been established.
Example: Syncope due to cardiac arrhythmia. Cardiac arrhythmia is the PDX, syncope is secondary diagnosis.
Do not assign a separate code at all for signs and symptoms that are routinely associated with a disease process.
Example: Viral gastroenteritis with fever, abdominal pain, nausea, vomiting, diarrhea. Code only viral gastroenteritis.
PDX Rule #5
When the original treatment plan is not carried out, the reason for admission remains the PDX.
Example: A patient with cholecystitis was admitted to the hospital for a cholecystectomy. Prior to surgery, the patient fell and sustained a left femur fracture. The surgery was canceled and a hip pinning was carried out on the second hospital day.
The PDX remains cholecystitis, since it necessitated the admission to the hospital. The fractured femur is sequenced as a secondary diagnosis since it occurred during the hospital stay.
PDX Rule #6
When the admission is for treatment of a complication resulting from surgery or other medical care, sequence the complication as the principal diagnosis.
The physician must indicate the condition is a “complication” or “due to” previous medical care/surgery in his or her documentation. A cause-and-effect relationship must be documented. The term “postop” by itself does not necessarily establish a cause-and-effect relationship.
PDX Rule #7
Medical observation: If admitted from observation, the principal diagnosis would be the medical condition which led to the hospital admission (not necessarily the condition requiring observation).
Postoperative observation: If admitted from observation following a procedure, then the PDX would be that condition that was chiefly responsible for the inpatient admission.
