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ICD-10-CM/PCS News Archives

ICD-10 and MS-DRGs – A Shifting of Logic

 
March 14, 2016:

It’s been nearly six months since ICD-10 implementation and the dust is just settling on how changes in MS-DRGs affect reimbursement. One thing is certain: coders must vigilantly attend to the DRG shifts that occurred during the transition from ICD-9.

At a broad level, ICD-10 DRG grouper logic was created in a way to use most of the same DRG codes as ICD-9. However, when HIM professionals dive deeper, ICD-10 presents new challenges that could significantly impact DRG-based revenue.

There are several areas where extra attention can help coders avoid the pitfalls of DRG shifts:

    1. Elimination of Codes: Some ICD-9 code options are not included in ICD-10 because clinical distinctions are no longer commonly used. For example, depressive disorder, not otherwise specified, and major depression had individual ICD-9 codes. ICD-10 reports both under the same code. Conversely, some procedures reported with a single code in ICD-9 require multiple codes in ICD-10.

    2. Importance of Sequencing: When working in ICD-10, coders must choose and assign codes in the correct order, or sequence, to ensure maximum reimbursement. The process requires physicians to provide more detailed documentation of encounters. Sequencing propels selection of the principal diagnosis, which is critical under ICD-10.

    3. Choosing Secondary Diagnoses: Once the principal diagnosis is assigned – at the highest severity level – coders can then choose the secondary diagnosis. The key here is to ensure classifications for complications/comorbidities (CCs) or major CCs (MCCs) are present, as these secondary codes change the DRG. Failure to assign the right CC or MCC, or not capture the secondary diagnosis, may result in lower reimbursement.

    4. Know the Coding Guidelines: Coders must also increase their knowledge of differences in coding guidelines between ICD-9 and ICD-10. These discrepancies come on many levels, including the selection of principal diagnosis. For example, anemia due to underlying malignancy has the anemia as the principal diagnosis in ICD-9; in ICD-10 the principal diagnosis is the malignancy. Some ICD-10 codes—mostly in the “Injury, Poisoning and Certain Other Consequences of External Causes” and “Pregnancy, Childbirth and the Puerperium” categories—feature a seventh character that identifies the encounter type. Miss that, or use the wrong character, and reimbursement takes a hit.

The MS-DRG shifts from ICD-9 to ICD-10 need not be daunting. Providers can empower coders through consistent training and feedback. Regular audits of how coders are sequencing and assigning primary and secondary diagnoses also will help identify problem areas. Above all, organizations should regularly engage coders and gather feedback on how to improve ICD-10 processes.

 

 
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