MS-DRG
Medicare Severity Diagnosis Related Groupstarted Oct 1 2007
ICD
international classification of diseases
CDI
Clinical Documentation Improvement
CM
Clinical Modification
PCS
Procedural Coding System
NCHS
National Center for Health Statistics
AHA
American Hospital Association
AHIMA
American Health Information Management Association
CMS
Centers for Medicare and Medicaid Services
NCHS
National Center for Health Statistics
HIPAA
Health Insurance Portability and Accountability Act
HCPCS
Healthcare Common Procedure Coding System
CPT
Current Procedural Terminology
code
3 character category that has no further subcategory
code subcatergory
has 4 or 5 characters
codes within a subcategory and 7th character rule
3 to 7 characters a code that has an applicable 7th character is considered invalid without it
1st, 2nd, 3rd digit
catergory
4tg. 5th. 6th digit
etiology, anatomical site, severity
7th digit
extension
first character and how many
section or general category of the procedure being describedthere are 17 different sections0-9 = medical surgical proceduresBCDFGHX =ancillary interventions performed in the inpatient setting
second character
body system or region of the body that is the focus of the procedurebreaks down by system (CNS/Urinary etc.) BUT ALSOby upper or lower body (upper bones, lower bones)
upper body
above the diaphragm
lower body
below the diaphragm
third character (how many)
Root operation/ Intent of Procedure31 different root operations that describe the objective of a procedure
fourth character
body partthe specific part of the body system on which the procedure is performedcan be entire organ, a lobe of an organ, a specific artery, etc.there is an appendix (body part key) in the PCS code book to assist in identifying what is considered a body part and what is not
appendix
has (body part key) in the PCS code book to assist in identifying what is considered a body part and what is notalso has a device key identifying manufacturer names of devices matched with appropriate PCS descriptions
Fifth character. how many
approachtechnique used to reach the site of the procedure7 different approaches that describe the point of access, method, and any instrument used
sixth character
devicedescribes whether a device was implantedalso further differentiates the type of device and its purpose
seventh character
qualifierunique meaning for different procedurescompletes code picturecode not complete until all 7 assignes
provider
A physician or other healthcare professional legally accountable for establishing a pt diagnosis exNP, PA in some states
ancillary acceptable use
PT, RN, dietitian when providing certain specificityex. BMI from dietitianPU stage from RNspecificity of debridement from WCCT / wound care nurse
acceptable terms at discharge to code if not ruled out as if it existed
probablesuspectedlikelypossiblestill to be ruled outborderline
Impending or Threatened Condition
Code any condition described at the time of discharge a s "impending" or "threatened" as follows: If it did occur, code as confirmed diagnosis. If it did NOT occur, reference the Alphabetic Index to determine if the condition has a subentry term for "impending" or "threatened" and also reference main term for "Impending and for "Threatened".
either/or
or similar wordingthen coding guidelines indicate that both conditions would be coded as confirmed and either can be sequenced as the pdx
integral to particular disease process
coding guidelines that should not code separately unless requires care beyond the usual dx tx. if goes beyond normal care then would code to capture a higher SOI and level of resource consumption
complications of surgery and medical care
...
HIV B20 (pdx vs secondary) vs R75
confirmed cases only, an exception to the possible and probable termsdoes not need positive test, only provider documentation of HIV positive with symptoms or has an HIV related illnesspdx if admission to treat HIV or related condition. secondary if admission unrelated to HIVR75 when has positive twst but no documented or confirmed dx
SOFA
Sequential Organ Failure Assessment
neoplasm primary and secondary
if the provider directs treatment to primary site. then that site must be pdxif provider directs treatment to the Mets site. then that would be pdx with primary site as secondary
anemia due to chemo receives blood, no other CA care
anemia is pdx
dehydration from nausea and vomiting due to chemo for breast CA and receives IV fluids and antibiotics without breast CA tx
dehydration pdxneoplasm as secondary
medication effect, taken correctly VS overdose ex
effect (ex.bradycardia) is pdx with the toxicity code as secondaryEXCEPT overdoseif acute resp failure following barbiturate overdose, the overdose is pdx with the resp failure as secondary
IPPS
inpatient prospective payment systemstarted in Oct 1983
RW and scale and how used
Relative weightscale 0-25 for intensity of services and resources consumed to treat the generalized Medicare populationRW is multiplied by the hospitals base rate (assigned by CMS, recalculated annually)
MedPAC
Medicare Payment Advisory Commission
MCC
major complication/comorbidity
CC
complication/comorbidity
Non-CC/MCC
no complication or comorbidity, do not significantly affect SOI or resource use
standalone DRG
MS-DRGs that have no additional tiers, not affected by cc/Mccs ex. CP, transient ischemia, gastroenteritis and pulmonary edema
MDC
Major diagnostic category
disproportionate share hospital adjustment
facilities that provide care to a higher percentage of low-income families receive an additional payment
indirect medical education adjustment
additional payments for approved teaching hospitalsvaries based on ratio of residents to beds /and/ residents to average daily census under IPPS
APR-DRG and levels
All Patient Refined Diagnosis-Related Group4 levels1.minor2.moderate3.major4.severe
pdx
Principal diagnosisprimary condition that resulted in admission and treatment to the inpatient setting
UHDDS
Uniform Hospital Discharge Data Setpdx may not be known on arrivalex, abd pain and SBO, discovered later to be cancercancer becomes pdx
secondary diagnosis and criteria
diagnosis other than the primary diagnosis for other conditions that are also affecting the patient at the time of the visitcriteria (one or more of):-clinical evaluation -therapeutic treatment -diagnostic procedures -extended LOS-increased nursing care and monitoring
factors that affect DRG
pdxsecondary dxproceduregenderDC statusbirth weight for neonate
CMI
Case-Mix indexaverage of the RE of the DRGs in a specified pt population over a set time frame
IOM
Institute of Medicine
POA and origin/hx
2007 CMS implemented POA vs acquired reporting policy, directly impacts reimbursement if HAC on case.
never events
29 serious reportable events grouped into 7 categories considered:-unambiguous (clearly identifiable and measurable)-serious (resulting in death or signf disability)-usually preventable
POA codes
Y NU unknownW clinically undetermined
MAC
Medicare Administrative Contractor
inpatient admission criteria
two midnight rule"CMS will reimburse hospitals for inpatient admissions if the admitting provider expects the pt to require a hosp stay that crossed 2 midnight and if the med record supports that reasonable expectation
RA
recovery audit (by CMS) started in 2003 under the Medicare Prescription Drug, Improvement, and Modernization Act
diagnosis at biggest risk for review
symptom dxchronic conditionssimple dx without cc/mccspecific DRGs with only 1 cc/mcc
PECOS
Provider, Enrollment, Chain and Ownership System
PQRS
Physician Quality Reporting System
IHI Triple Aim
Institute for Healthcare ImprovementA framework that describes an approach to optimizing health system performance. It is believed that new designs must be developed to simultaneously pursue three dimensions,":-Improving the patient experience of care (including quality and satisfaction);-Improving the health of populations; andReducing the per capita cost of health care.-Cost per capita, experience of care, population health
O/E mortality rate, definition, and how calculated. what does lower score mean, and what does higher score mean
observed to expected mortality rateobserved mortality- the actual # of patients who died in the hospital each month expected mortality- the expected average of numbers of deaths of hospital patients with a particular illness or condition that is beyond the control of the medical center..and other factors such as age, gender and other medical problemsobserved ÷ expected = O/E ratiolower score= fewer pts expired than expectedhigher score = opposite1.5= higher than expected1= equal to what is expected 0.75=25% lower than expected 0.5=50% lower than expected
4 quality metrics used by CMS
HVBP (hospital value-based purchasing)HACRP (hospital acquired condition reduction program)HRRP (hospital readmissions reduction program)30day mortality measures
HVBP
Hospital Value Based Purchasing started 2013 by CMs to reward acute care hospitals with incentive payments when meeting certain quality of care standards
PSI-90
weighted average of 10 specific
AHRQ
Agency for Healthcare Research and Quality
the 6 conditions/procedures measured in the HRRP (for excessive readmission ratios) program
AMICOPDHFPNACABGelective total hip or knee
readmission (and exclusion)
within 30 days from same or another acute care hospitalexclusions:left AMApts older than 65few other variables depending on dx
30 day mortality measure
estimates of death from any cause within 30days of hospital admission, for pts hospitalized with one or several certain dx/procedures