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February 1, 2018


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ICD-10-CM/PCS News Archives

Guideline Changes Affect DRG Assignment in ICD-10

 
March 14, 2016:

Now that the ICD-10 implementation is in the rear-view mirror, coders have plenty of ICD-10 road hazards to keep an eye on. One big hazard is coding guidelines. Coders who understand how ICD-10 made guideline changes necessary will find success in reducing errors and maximizing reimbursement for their organizations.

The following examples shed light on how ICD-10 logic alters how many MS-DRGs are assigned (differences are in italics).

Example #1 – Anemia Due to Malignancy

ICD-9-CM Guideline: When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate anemia code is designated as the principal diagnosis and is followed by the appropriate code(s) for the malignancy. Average hospital payment: $4,210.54.

ICD-10-CM Guideline: When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the appropriate code for the anemia. Average hospital payment: $3,556.93.

Example #2 - Fracture in Patient with Osteoporosis

ICD-9-CM Guideline: A pathologic fracture is defined as a break in a diseased bone due to weakening of the bone structure by pathologic processes (such as osteoporosis or bone tumors) without any identifiable trauma or following only minor trauma. Only the physician can make the determination that the fracture is out of proportion to the degree of trauma. X-ray indications of diseased bone may be used by the physician to arrive at a diagnosis of a pathologic fracture, but should not be used by coders to make this determination. Average hospital payment: $3,991.78.

ICD-10-CM Guideline: Osteoporosis with current pathological fracture is for patients who have a current pathologic fracture at the time of an encounter. The codes under M80 identify the site of the fracture. A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone. Average hospital payment: $4,285.43.

We could cite other examples if we had the space (you can find the full CMS guidelines here). As these and other cases illustrate, coders need to pay careful attention to the effects of DRG shifts. Understanding how to sequence codes from the patient encounter, incorporate a seventh character for encounter type when appropriate and ensuring specificity in documentation can help coders increase their value within their organizations.

 

 
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