DRG Expert th Edition. A comprehensive guidebook to the MS-DRG classification system

Transcription

1 DRG Expert A comprehensive guidebook to the MS-DRG classification system Changes effective with discharges on or after October 1, th Edition

2 Contents Numeric Listing of DRGs... i DRG Listing by Major Diagnostic Category... xiii Introduction... xxv Pre MDC... 1 MDC 1 Diseases And Disorders Of The Nervous System... 5 MDC 2 Diseases And Disorders Of The Eye MDC 3 Diseases And Disorders Of The Ear, Nose, Mouth And Throat MDC 4 Diseases And Disorders Of The Respiratory System MDC 5 Diseases And Disorders Of The Circulatory System MDC 6 Diseases And Disorders Of The Digestive System MDC 7 Diseases And Disorders Of The Hepatobiliary System And Pancreas MDC 8 Diseases And Disorders Of The Musculoskeletal System And Connective Tissue MDC 9 Diseases And Disorders Of The Skin, Subcutaneous Tissue And Breast MDC 10 Endocrine, Nutritional And Metabolic Diseases And Disorders MDC 11 Diseases And Disorders Of The Kidney And Urinary Tract MDC 12 Diseases And Disorders Of The Male Reproductive System MDC 13 Diseases And Disorders Of The Female Reproductive System MDC 14 Pregnancy, Childbirth And The Puerperium MDC 15 Newborns And Other Neonates With Conditions Originating In The Perinatal Period MDC 16 Diseases And Disorders Of The Blood And Blood-Forming Organs And Immunological Disorders MDC 17 Myeloproliferative Diseases And Disorders And Poorly Differentiated Neoplasms MDC 18 Infectious And Parasitic Diseases MDC 19 Mental Diseases And Disorders MDC 20 Alcohol/Drug Use And Alcohol/Drug-Induced Organic Mental Disorders MDC 21 Injury, Poisoning And Toxic Effects Of Drugs MDC 22 Burns MDC 23 Factors Influencing Health Status And Other Contacts With Health Services MDC 24 Multiple Significant Trauma MDC 25 Human Immunodeficiency Virus Infections DRGs Associated with All MDCs Alphabetic Index to Diseases Numeric Index to Diseases Alphabetic Index to Procedures Numeric Index to Procedures Appendix A Lists of CCs and MCCs... Appendix 1 Appendix B List of Transfer and Special Payment DRGs... Appendix 69 Appendix C DRG Surgical Hierarchy Table... Appendix 73 Appendix D MS-LTC-DRG Crosswalk.. Appendix 77 Appendix E National Average Payment Table... Appendix 95 Appendix F MDC Assignment of ICD-9-CM Codes... Appendix 113

3 MDC 1 Diseases And Disorders Of The Nervous System SURGICAL DRG y 020 Diagnosis of Hemorrhage s with y MCC GMLOS 14.8 AMLOS 18.3 RW Principal Diagnosis Syphilitic ruptured cerebral aneurysm 430 Subarachnoid hemorrhage 431 Intracerebral hemorrhage 432* Other and unspecified intracranial hemorrhage Operating Room Procedures Ligation of meningeal vessel Incision of intracranial Endarterectomy of intracranial Resection of intracranial with anastomosis Resection of intracranial with replacement Ligation and stripping of varicose veins of intracranial Other excision of intracranial Other surgical occlusion of intracranial Extracranial-intracranial (EC-IC) vascular bypass Clipping of aneurysm Other repair of aneurysm Repair of arteriovenous fistula Endovascular repair or occlusion of head and neck Other endovascular repair (of aneurysm) of other DRG y 021 Diagnosis of Hemorrhage s with y CC GMLOS 13.7 AMLOS 15.5 RW Select principal diagnosis and operating room procedures listed under DRG 020 DRG y 022 Diagnosis of Hemorrhage without GMLOS 7.6 AMLOS 9.3 RW Select principal diagnosis and operating room procedures listed under DRG 020 DRG y 023 Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis s with y MCC or Chemo Implant GMLOS 8.9 AMLOS 12.7 RW Operating Room Procedures Percutaneous angioplasty or atherectomy of intracranial vessel(s) Open biopsy of cerebral meninges Open biopsy of brain Biopsy of skull Other diagnostic procedures on brain and cerebral meninges Other diagnostic procedures on skull Incision and drainage of cranial sinus Removal of intracranial neurostimulator lead(s) Reopening of craniotomy site Other craniotomy Other craniectomy Placement of intracerebral catheter(s) via burr hole(s) Incision of cerebral meninges Lobotomy and tractotomy Other incision of brain Operations on thalamus Operations on globus pallidus Excision of lesion or tissue of cerebral meninges Hemispherectomy Lobectomy of brain Other excision or destruction of lesion or tissue of brain 01.6 Excision of lesion of skull 02.0* Cranioplasty 02.1* Repair of cerebral meninges 02.2 Ventriculostomy Lysis of cortical adhesions Repair of brain Implantation or replacement of intracranial neurostimulator lead(s) Insertion or replacement of skull tongs or halo traction device Other operations on skull, brain, and cerebral meninges Excision of acoustic neuroma Decompression of trigeminal nerve root Biopsy of pituitary gland, transfrontal approach Biopsy of pituitary gland, transsphenoidal approach Biopsy of pituitary gland, unspecified approach Biopsy of pineal gland 07.5* Operations on pineal gland 07.6* Hypophysectomy 07.7* Other operations on hypophysis Division of glossopharyngeal nerve Incision of intracranial Endarterectomy of intracranial Resection of intracranial with anastomosis Resection of intracranial with replacement Ligation and stripping of varicose veins of intracranial Other excision of intracranial Other surgical occlusion of intracranial Extracranial-intracranial (EC-IC) vascular bypass Clipping of aneurysm Other repair of aneurysm Repair of arteriovenous fistula MDC 1: Diseases And Disorders Of The Nervous System SURGICAL Surgical Medical CC Indicator MCC Indicator Procedure Proxy 2008 Ingenix Valid 10/01/ /30/2009 5

4 Appendix B List of Transfer and Special Payment DRGs Transfer DRGs 003 ECMO or Tracheostomy with Mechanical Ventilation 96+ Hrs or Principal Diagnosis Except Face, Mouth & Neck w Major O.R. 004 Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth & Neck w/o Major O.R. 025 Craniotomy & Endovascular Intracranial Procedures w MCC 026 Craniotomy & Endovascular Intracranial Procedures w CC 027 Craniotomy & Endovascular Intracranial Procedures w/o 031 Ventricular Shunt Procedures w MCC 032 Ventricular Shunt Procedures w CC 033 Ventricular Shunt Procedures w/o 054 Nervous System Neoplasms w MCC 055 Nervous System Neoplasms w/o MCC 056 Degenerative Nervous System Disorders w MCC 057 Degenerative Nervous System Disorders w/o MCC 064 Intracranial Hemorrhage or Cerebral Infarction w MCC 065 Intracranial Hemorrhage or Cerebral Infarction w CC 066 Intracranial Hemorrhage or Cerebral Infarction w/o 070 Nonspecific Cerebrovascular Disorders w MCC 071 Nonspecific Cerebrovascular Disorders w CC 072 Nonspecific Cerebrovascular Disorders w/o 085 Traumatic Stupor & Coma, Coma <1 Hr w MCC 086 Traumatic Stupor & Coma, Coma <1 Hr w CC 087 Traumatic Stupor & Coma, Coma <1 Hr w/o 091 Other Disorders of Nervous System w MCC 092 Other Disorders of Nervous System w CC 093 Other Disorders of Nervous System w/o 100 Seizures w MCC 101 Seizures w/o MCC 163 Major Chest Procedures w MCC 164 Major Chest Procedures w CC 165 Major Chest Procedures w/o 166 Other Resp System O.R. Procedures w MCC 167 Other Resp System O.R. Procedures w CC 168 Other Resp System O.R. Procedures w/o 175 Pulmonary Embolism w MCC 176 Pulmonary Embolism w/o MCC 177 Respiratory Infections & Inflammations w MCC 178 Respiratory Infections & Inflammations w CC 179 Respiratory Infections & Inflammations w/o 186 Pleural Effusion w MCC 187 Pleural Effusion w CC 188 Pleural Effusion w/o 190 Chronic Obstructive Pulmonary Disease w MCC 191 Chronic Obstructive Pulmonary Disease w CC 192 Chronic Obstructive Pulmonary Disease w/o 193 Simple Pneumonia & Pleurisy w MCC 194 Simple Pneumonia & Pleurisy w CC 195 Simple Pneumonia & Pleurisy w/o 196 Interstitial Lung Disease w MCC 197 Interstitial Lung Disease w CC 198 Interstitial Lung Disease w/o 205 Other Respiratory System Diagnoses w MCC 206 Other Respiratory System Diagnoses w/o MCC 207 Respiratory System Diagnosis w Ventilator Support 96+ Hours 216 Cardiac Valve & Other Major Cardiothoracic Procedures w Cardiac Catheterization w MCC 217 Cardiac Valve & Other Major Cardiothoracic Procedures w Cardiac Catheterization w CC 218 Cardiac Valve & Other Major Cardiothoracic Procedures w Cardiac Catheterization w/o 228 Other Cardiothoracic Procedures w MCC 229 Other Cardiothoracic Procedures w CC 230 Other Cardiothoracic Procedures w/o 233 Coronary Bypass w Cardiac Catheterization w MCC 234 Coronary Bypass w Cardiac Catheterization w/o MCC 235 Coronary Bypass w/o Cardiac Catheterization w MCC 236 Coronary Bypass w/o Cardiac Catheterization w/o MCC 239 Amputation for Circulatory System Disorders Except Upper Limb & Toe w MCC 240 Amputation for Circulatory System Disorders Except Upper Limb & Toe w CC 241 Amputation for Circulatory System Disorders Except Upper Limb & Toe w/o 242 Permanent Cardiac Pacemaker Implant w MCC 243 Permanent Cardiac Pacemaker Implant w CC 244 Permanent Cardiac Pacemaker Implant w/o 255 Upper Limb & Toe Amputation for Circulatory System Disorders w MCC 256 Upper Limb & Toe Amputation for Circulatory System Disorders w CC 257 Upper Limb & Toe Amputation for Circulatory System Disorders w/o 264 Other Circulatory System O.R. Procedures 280 Acute Myocardial Infarction, Discharged Alive w MCC 281 Acute Myocardial Infarction, Discharged Alive w CC 282 Acute Myocardia Infarction, Discharged Alive w/o 288 Acute & Subacute Endocarditis w MCC 289 Acute & Subacute Endocarditis w CC 290 Acute & Subacute Endocarditis w/o 291 Heart Failure & Shock w MCC 292 Heart Failure & Shock w CC 293 Heart Failure & Shock w/o 299 Peripheral Vascular Disorders w MCC 300 Peripheral Vascular Disorders w CC 301 Peripheral Vascular Disorders w/o 314 Other Circulatory System Diagnoses w MCC 315 Other Circulatory System Diagnoses w CC Appendix B Transfer DRGs 2008 Ingenix Appendix 69

5 Appendix D MS-LTC-DRG Crosswalk 1 The SSO Threshold is calculated as 5/6th of the geometric average length of stay of the MS-LTC-DRG (as specified in in conjunction with ). * In determining the MS-LTC-DRG relative weights for FY 2009, these MS-LTC-DRGs were adjusted for nonmonotonicity as discussed in section II.I.4. (step 6) of the preamble of the final rule. MS-LTC-DRG Base MS-LTC-DRG MS-LTC-DRG Title FY 2007 LTCH Cases Relative Weight Geometric Avg Length of Stay Short-Stay Outlier (SSO) Threshold Heart transplant or implant of heart assist system w MCC Heart transplant or implant of heart assist system w/o MCC ECMO or trach w MV 96+ hrs or PDX exc face, mouth & neck w maj O.R Trach w MV 96+ hrs or PDX exc face, mouth & neck w/o maj O.R Liver transplant w MCC or intestinal transplant Liver transplant w/o MCC Lung transplant Simultaneous pancreas/kidney transplant Bone marrow transplant Pancreas transplant Tracheostomy for face,mouth & neck diagnoses w MCC Tracheostomy for face,mouth & neck diagnoses w CC Tracheostomy for face,mouth & neck diagnoses w/o Intracranial vascular procedures w PDX hemorrhage w MCC Intracranial vascular procedures w PDX hemorrhage w CC Intracranial vascular procedures w PDX hemorrhage w/o Craniotomy w major device implant or acute complex CNS PDX w MCC* Craniotomy w major device implant or acute complex CNS PDX w/o MCC* Craniotomy & endovascular intracranial procedures w MCC Craniotomy & endovascular intracranial procedures w CC Craniotomy & endovascular intracranial procedures w/o Spinal procedures w MCC Spinal procedures w CC Spinal procedures w/o Ventricular shunt procedures w MCC Ventricular shunt procedures w CC Ventricular shunt procedures w/o Carotid artery stent procedure w MCC Carotid artery stent procedurew CC Carotid artery stent procedure w/o Extracranial procedures w MCC Extracranial procedures w CC* Extracranial procedures w/o Periph & cranial nerve & other nerv syst proc w MCC Periph & cranial nerve & other nerv syst proc w CC Periph & cranial nerve & other nerv syst proc w/o * Spinal disorders & injuries w Appendix D MS-LTC-DRG Crosswalk 2008 Ingenix Appendix 77