2. Inpatient Prospective Payment System

Question 1

When did Medicare begin reimbursement based on actual charges?

Answer 1

1965

Question 2

When did Medicare begin using a fixed payment system?

Answer 2

1983

Question 3

Who created the DRG system?

Answer 3

Robert Barclay Fetter and John Devereaux Thompson at Yale University

Question 4

When did Medicare adjust the DRG for severity with the creation oft the Medicare Severity (MS) DRG?

Answer 4

2007

Question 5

What was the intention of the DRG?

Answer 5

Patient classification system that relates types of patients treated to the expected resources they consume

Question 6

How does a DRG work?

Answer 6

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.

Question 7

What is the CMS DRG Definitions Manual?

Answer 7

The document that contains the history, design and classification rules of the DRG system, as well as its application to patient discharge data

Question 8

How are DRGs assigned?

Answer 8

DRGs are assigned by a grouper software program based on ICD diagnoses, procedures, age, sex, discharge status and the presence of complications and comorbidities

Question 9

When does CMS publish annual updates/changes in the Federal Register? When are updates effective?

Answer 9

August 1 & October 1

Question 10

What is the purpose of a severity-adjusted DRG?

Answer 10

To quantify differences in demographic and clinical risk factors among patients and to compare clinical outcomes (mortality/complications) and utilization measures (LOS, cost)

Question 11

SOI

Answer 11

Severity of Illness. The extent of physiologic decompensation or organ system loss of function.

How sick is the patient.

Question 12

ROM

Answer 12

Risk of Mortality. The likelihood of dying

Question 13

Resource Intensity

Answer 13

The relative amount and type of diagnostic, therapeutic and bed services used in management of a particular disease

Question 14

What are the four subclasses of SOI and ROM?

Answer 14

1-minor, 2-moderate, 3-major and 4-extreme

MMME

Question 15

What are the 6 factors that determine DRG assignment?

Answer 15

Principle diagnosis, procedures performed, specific secondary diagnoses, age, sex and discharge disposition

Question 16

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

Answer 16

Pneumonia ICD-9-CM 486

Simple Pneumonia and Pleurisy DRGs 193-195

Question 17

What is the PDX?

Patient is admitted with acute exacerbation of CHF and Pneumonia. Admit to ICU. admin IV diuretic and IV abx.

Answer 17

Either can be sequenced as PDX.
Which diagnosis consumed the most resources?
Required the most M.E.A.T.

Question 18

PDX Rule #1

Answer 18

When two or more diagnoses equally meet the criteria for principal diagnosis EITHER of the diagnoses may be sequenced first.

Question 19

PDX Rule #2

Answer 19

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

Question 20

PDX Rule #3

Answer 20

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.

Question 21

PDX Rule #4

Answer 21

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.

Question 22

PDX Rule #5

Answer 22

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.

Question 23

PDX Rule #6

Answer 23

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.

Question 24

PDX Rule #7

Answer 24

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.

Question 25

PDX Rule #8

Answer 25

If admitted following an outpatient surgery due to a complication of the surgery, assign the complication as PDX.

Question 26

PDX Rule #9

Answer 26

When two or more contrasting or comparative diagnoses are documented as “either/or” (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission.

If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.

If no complication or other condition is documented as the reason for admission, assign the reason for the surgery as PDX

Question 27

PDX Rule #10

Answer 27

When a symptom(s) is followed by contrasting/comparative (“or”) diagnoses, the symptom is sequenced first. All the contrasting/comparative diagnoses should be sequenced as secondary conditions.

Example 1: Chest pain due to either angina oresophageal spasm. Chest pain is the PDX, with angina and esophageal spasm as additional diagnoses.

Example 2: Syncope: CVA vs. cardiac arrhythmia. Syncope is the
PDX, with CVA & cardiac arrhythmia as secondary diagnoses.

Question 28

A patient was discharged two days following a hysterectomy. On the second day at home, she strained lifting a small child. She was readmitted with wound dehiscence.
What is the PDX?

Answer 28

Wound dehiscence

Question 29

A patient is admitted with respiratory failure and large iatrogenic pneumothorax 3 days following outpatient thoracentesis for malignant pleural effusion.
What is the PDX?

Answer 29

Iatrogenic pneumothorax

Question 30

A patient is treated in an observation unit for 16 hours with an exacerbation of COPD, then admitted as an inpatient for treatment of a pulmonary embolism discovered on chest CT. What is the PDX?

Answer 30

Pulmonary embolism

Question 31

Patient admitted for postoperative bleeding following outpatient TURP.
What is PDX?

Answer 31

Postoperative bleeding

Question 32

“Acute pancreatitis vs. acute cholecystitis”

What is the PDX?

Answer 32

Either can be sequenced as the PDX

Question 33

Chest pain due to either angina or esophageal spasm.

What is the PDX?

Answer 33

Chest pain.

Other dx can be listed a secondary

Question 34

“Syncope: CVA vs. cardiac arrhythmia”

What is the PDX?

Answer 34

Syncope

Question 35

All invasive or surgical procedures are considered valid, reimbursable principle procedures. T/F?

Answer 35

False

Question 36

Endotracheal intubation with mechanical ventilation is considered a surgical DRG. T/F?

Answer 36

False. The procedure is listed with the Medical DRGs.

Question 37

What is the purpose of Consolidated severity adjusted DRGs?

Answer 37

To QUANTIFY differences in demographic and clinical risk factors among patients and to compare clinical outcomes (morality, complications) and utilization measures (LOS, cost)

Question 38

How is a hospital reimbursed?

Answer 38

The facility’s BLENDED RATE is multiplied by a DRG’s RELATIVE WEIGHT to determine Medicare payment for treating a patient in that DRG. The blended rate does NOT reflect severity of illness of complexity of service.

MS-DRG RW x Facility BLENDED RATE

Question 39

CMI

Answer 39

Case Mix Index
The SUM of all MS-DRG Relative Weights
Divided By
The TOTAL of all Medicare Cases

Impacted by: service type, volume of medical-surgical cases and MS-DRG assignments