MS-DRGs Under ICD-10: A Look at the Draft MS-DRG Mappings and CC Lists

MS-DRGs Under ICD-10: A Look at the Draft MS-DRG Mappings and CC Lists Presented by: Lynn-Marie Wozniak, MS, RHIT April 25, 2013

Presentation Objectives By the completion of this webinar participants will be able to do (or know) the following: Review the process used to convert the MS-DRG Grouper from ICD-9-CM to ICD-10-CM/PCS Access and navigate the V30.0 Draft MS-DRG Manual to find specific MS- DRG criteria as well as MCC/CC lists, CC exclusions and surgical hierarchies. Recognize similarities and differences between the current MCC and CC lists and the ICD-10-CM based lists Identify the affect that the ICD-10-CM/PCS codes and the code mappings have on the assignment of cases to high volume MS-DRGs Determine which high-volume MS-DRGs will be most affected by the transition to ICD-10-CM/PCS

CMS MS-DRG Conversion Project: I-9 to I-10 Goal: to develop an ICD-10 MS-DRG grouper that produces the same results as the ICD-9-CM MS-DRG grouper Same MS-DRG structure Same MS-DRGs Same surgical hierarchy Same MS-DRG definitions and criteria Replaced all the ICD-9-CM code lists with corresponding ICD-10-CM/PCS lists

Process Used to Replace ICD-9-CM Code Lists with ICD-10- CM/PCS Code Lists in MS-DRG Grouper Goal: Include all possible ICD-10-CM/PCS codes in the converted MS-DRG Grouper ICD-10-CM/PCS codes that had a one-to-one mapping (GEMs) with an ICD-9-CM code were mapped to the same DRG(s) as the ICD-9-CM code. ICD-10-CM/PCS codes that did not have any mapping back to ICD-9-CM (about 500 codes) had an ICD-9-CM code assigned to them for grouping purposes by the experts involved in the conversion project ICD-10-CM/PCS codes that mapped to multiple ICD-9-CM codes that were assigned to different DRGs had to be reviewed and decision made as to where best to put them. If one of the ICD-9-CM codes was dominant by more than 20% in terms frequency of occurrence, the ICD-10-CM/PCS code was mapped to it, if not, ICD-10-CM/PCS code assigned to the closest matching ICD-9-CM codes in terms of definition and diagnoses classified to it.

ICD-10-CM to ICD-9-CM GEMS: Reverse Look-Up Sample of I-10 to 1-9 GEMS : COPD Codes J40 490 00000 J410 4910 00000 J411 4911 00000 J418 4918 10000 J42 4919 00000 J430 4928 10000 J431 4928 10000 J432 4928 10000 J438 4928 10000 J439 4920 10000 J439 4928 10000 J440 49122 10000 J440 49321 10000 J441 49121 10000 J441 49322 10000 J449 49120 10000 J449 49320 10000 J449 496 10000 ICD-10- CM Codes ICD-9- CM Codes

Mapping Example: MS-DRG 069 Transient Ischemia ICD-9-CM Codes PRINCIPAL DIAGNOSIS 4350 Basilar artery syndrome 4351 Vertebral artery syndrome 4352 Subclavian artery syndrome 4353 Vertebrobasilar artery syndrome 4358 Transient cerebral ischemia, NEC 4359 Transient cerebral ischemia, NOS 4371 Acute cerebrovascular insufficiency ICD-10-CM Codes PRINCIPAL DIAGNOSIS G450 Vertebro-basilar artery syndrome G451 Carotid artery syndrome (hemispheric) G452 Multiple and bilateral precerebral artery syndromes G458 Other transient cerebral ischemic attacks and related syndromes G459 Transient cerebral ischemic attack, unspecified G460 Middle cerebral artery syndrome G461 Anterior cerebral artery syndrome G462 Posterior cerebral artery syndrome I6781 Acute cerebrovascular insufficiency I6782 Cerebral ischemia I67841 Reversible cerebrovascular vasoconstriction syndrome I67848 Other cerebrovascular vasospasm and vasoconstriction I6789 Other cerebrovascular disease The ICD-10-CM principal diagnosis codes classified to MS-DRG 069 consist of all the ICD-10-CM codes in the GEMs that are mapped to the ICD-9-CM principal diagnosis codes in first column.

ICD-10-CM Codes That Do Not Map to any ICD-9-CM Code The experts involved in the conversion project mapped the ICD-10-CM codes that were not included in the GEMs to ICD-9-CM codes, MDCs and MS-DRGs. ICD-10-CM ICD-9-CM MDC and MS-DRG G43.2, Status migrainosus T36-50**6*, Underdosing (489 codes), 346.92, Migraine, unspecifed, without mention of intractable migraine with status migrainosus V58.69, Long-term (current) use of other medications Z66, Do not resusictate V68.89, Encounters for other specified administrative purpose Z67*, Blood type (10 codes) V68.89, Encounters for other specified administrative purpose MDC 1 Headaches (MS-DRGs102-103) MDC 23 Aftercare (MS-DRGs 949-950) MDC 23 Other Factors Influencing Health Status (MS-DRG 951) MDC 23 Other Factors Influencing Health Status ( MS-DRG 951) CMS.gov/Medicare/Coding/ICD-10-MS-DRG Conversion Project.html: Converting MS-DRGs 26.0 to ICD-10-CM and ICD-10-PCS Updated 2/25/13 with new impact article [Zip.612KB]

Mapping Example: ICD-10-CM Code Mapped to More Than One ICD- 9-CM Code ICD-10-CM Code ICD-9-CM Codes MS-DRG List FY 2007 MedPAR Records K22.8 Other specified diseases of esophagus Includes: Hemorrhage of esophagus NOS 530.82 Esophageal hemorrhage Major Esophageal Disorders (MS-DRGs 368-370) 10,167 K22.8 Other specified diseases of esophagus Includes: Hemorrhage of esophagus NOS 530.89 Other diseases of esophagus Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders (MS-DRGs 391-392) 8,685 CMS.gov/Medicare/Coding/ICD-10-MS-DRG Conversion Project.html: Converting MS-DRGs 26.0 to ICD-10-CM and ICD-10-PCS Updated 2/25/13 with new impact article [Zip.612KB]

ICD-10-CM to ICD-9-CM GEMS: Reverse Look-Up Sample of I-10 to 1-9 GEMS : COPD Codes J40 490 00000 J410 4910 00000 J411 4911 00000 J418 4918 10000 J42 4919 00000 J430 4928 10000 J431 4928 10000 J432 4928 10000 J438 4928 10000 J439 4920 10000 J439 4928 10000 J440 49122 10000 J440 49321 10000 J441 49121 10000 J441 49322 10000 J449 49120 10000 J449 49320 10000 J449 496 10000 Sample of Reimbursement GEMS: COPD Codes J40 1 490 J410 1 4910 J411 1 4911 J418 1 4918 J42 1 4919 J430 1 4928 J431 1 4928 J432 1 4928 J438 1 4928 J439 1 4928 J440 1 49122 J441 1 49121 J449 1 496

Special Challenges Involving Mapping ICD-10-PCS Codes to ICD- 9-CM in MS-DRG Grouper Many to One Multiple ICD-10-PCS codes mapped to a single ICD-9-CM procedure code due to ICD-10-PCS having a separate version of a code for each body system/body part, and ICD-9-CM having only one code that does not specify body part In ICD-9-CM the single code is classified to multiple MS-DRGs. In ICD-10-PCS the codes were distributed among the MS-DRGs based on body system/body part in the code. Example 92.27, Implantation or insertion of radioactive elements (1 code, in 12 MDCs, 35 MS- DRGs) 0xHxx1Z, Root operation is Insertion, and the device is Radioactive Element and there is no qualifier, but the body system, body part and approach changeable. This equals dozens of codes. Project experts assigned the specific ICD-10-PCS implantation or insertion of radioactive element codes to the 12 MDCs and 35 MS- DRGs on the basis of the body system/part involved, matching it to each MDC and then the MS-DRGs within the MDC.

Special Challenges Involving Mapping ICD-10-PCS Codes to ICD- 9-CM in MS-DRG Grouper MDC Body System Map CMS.gov/Medicare/Coding/ICD-10-MS-DRG Conversion Project.html: Converting MS-DRGs 26.0 to ICD-10-CM and ICD-10-PCS Updated 2/25/13 with new impact article [Zip.612KB] APPENDIX B

Special Challenges Involving Mapping ICD-10-PCS Codes to ICD- 9-CM in MS-DRG Grouper One to Many For ICD-10 codes that translate to multiple single ICD-9 codes in the GEMs, one ICD-9 code was selected for reimbursement purposes. For ICD-10 codes that translate to multiple ICD-9 clusters in the GEMs, one ICD-9 cluster was selected for reimbursement purposes. The mapping of one ICD-10 may require as many as six ICD-9 codes to reproduce the meaning of the ICD-10 code. In such cases, where an ICD-10 code maps to an ICD-9 cluster, all the codes in the cluster were included.

Examples of ICD-10-PCS Mapped to ICD-9-CM Code Clusters

Converting the CC and MCC Lists from ICD-9-CM to ICD-10-CM Start with ICD-10-CM to ICD-9-CM GEMS Flag all the ICD-9-CM codes on the GEMS that are on the CC or MCC list Select all the ICD-10-CM codes that are mapped to an ICD-9-CM CC and MCC code for the ICD- 10-CM CC and MCC List. If map to multiple CC codes it is a CC If map to multiple MCC codes it is a MCC If map to a CC and an MCC, or a CC and a non- CC, then dominant code was picked. If no dominant code, expert panel picked. ICD-10-CM Codes (Put all the codes that are mapped to ICD- 9-CM CCs or MCCs on the CC or MCC list) ICD-9-CM Codes (flag all the codes on the CC and MCC list)

Results of CC and MCC List Conversions Conversion Summary MCC CC Total ICD-9-CM CCs and MCCs on List 1,592 3,427 5,019 ICD-10-CM Codes Auto-translated 3,152 13,594 16,845 ICD-10-CM List Conflicts 99 (82 resolved based on frequency; 17 resolved by expert panel) ICD-9-CM CCs and MCCs with no corresponding ICD-10-CM Codes (examples: Uncontrolled diabetes codes, GI ulcers with obstructions, Multiple unspecified injury codes) 43 55 98 CMS.gov/Medicare/Coding/ICD-10-MS-DRG Conversion Project.html: Converting MS-DRGs 26.0 to ICD-10-CM and ICD-10-PCS Updated 2/25/13 with new impact article [Zip.612KB]

Principal Diagnosis is Its Own CC Cytomegaloviral hepatitis Sickle-cell disease with acute chest syndrome Diabetes mellitus with diabetic peripheral angiopathy with gangrene Atherosclerotic heart disease with unstable angina pectoris Atherosclerosis of leg(s) with ulceration/gangrene of thigh/calf/ankle/foot/other/unspecified site Raynaud's syndrome with gangrene Crohn's disease with intestinal obstruction/fistula/abscess Colitis(ulcerative) (chronic) (pan) (left-sided) with intestinal obstruction/fistula/abscess Inflammatory polyps of colon with intestinal obstruction/fistula/abscess Diverticulitis of small/large intestine with perforation and abscess w/ or w/o bleeding Calculus of bile duct with (acute) (chronic) cholangitis, with or without obstruction Reiter's disease (specify site(s)) Rheumatoid myopathy with rheumatoid arthritis (specify site(s)) Endocarditis/pericarditis in systemic lupus erythematosus Dermatopolymyositis/polymyositis with myopathy Systemic sclerosis with lung involvement/ myopathy Sicca syndrome with myopathy Osteonecrosis in diseases classified elsewhere (specify site(s)) Chronic obstructive pyelonephritis Gestational edema with proteinuria (specify trimester) Encounter for aftercare following transplant (specify organ(s))

Principal Diagnosis is Its Own MCC Anthrax, candidal, erysipelothrix, gonococcal or listerial sepsis Whooping cough due to Bordetella pertussis/parapertussis/other Bordetella species with pneumonia Cytomegaloviral pneumonitis or pancreatitis Invasive pulmonary aspergillosis Cerebral cryptococcosis Ascariasis pneumonia Septic/saddle/other pulmonary embolism with acute cor pulmonale Alcoholic hepatic failure with coma Toxic liver disease with hepatic necrosis, with coma Acute and subacute, or chronic hepatic failure with coma Pressure ulcer (specify site), stage 3 or stage 4 Severe sepsis with septic shock Traumatic cerebral edema without loss of consciousness, initial encounter Traumatic cerebral edema with loss of consciousness, (specify time), initial encounter

Other Issues That Had to be Resolved During Conversion Mapped 1 st, 2 nd and 3 rd trimester OBcodes to antepartum codes with 5 th digit 3. Mapped delivery codes to OB codes with 5 th digit 2, and post-partum to OB codes with 5 th digit 4 Mapped subsequent and sequela encounter codes to Aftercare and Late effect codes OB Codes Subsequent and Sequela Antepartum codes Delivery codes Postpartum codes Aftercare codes Late effect codes

Example of Other Issues: MS-DRGs 466-468, Revision of Hip and Knee Replacement Joint revision procedure codes mapped to ICD-9-CM codes in three different MS-DRGs Required combinations of ICD-10-CM codes to get cases to go to revision MS-DRGs 466-468. Example: 0SR90J5 Replacement of Right Hip Joint with Synthetic Substitute, Metal on Polyethylene, Open Approach And 0SP90JZ, Removal of Synthetic Substitute from Right Hip Joint, Open Approach

Example of Other Issues: MS-DRGs 466-468 (partial list)

CMS.gov Website

CMS.gov/Medicare

CMS.gov/Medicare ICD-10 link

CMS.gov/Medicare/ICD-10

CMS.gov/Medicare/ICD-10/GEMS

CMS.gov/Medicare/ICD-10/Conversion Project

CMS.gov/Medicare/ICD-10/Conversion Project

MS-DRG Manual Table of Contents

Index to MS-DRGs

MS-DRG 069: Transient Ischemia

MS-DRG Manual Table of Contents

MDC 4: MS-DRG Chart

MS-DRGs 207 and 208 Code Lists and Grouper Logic

MS-DRG Manual Table of Contents

Appendix A: List of MS-DRGs

Appendix B: Diagnosis Code/MDC/MS-DRG Index

Appendix C: CC and MCC Exclusion List

Appendix C: Pop-up Exclusion List

Appendix D: Surgical Hierarchy MDC 06,Diseases & Disorders of the Digestive System Surgical Hierarchy MS-DRGs Stomach, Esophageal and Duodenal Procedures 326-328 Major Small and Large Bowel Procedures 329-331 Rectal Resection 332-334 Peritoneal Adhesiolysis 335-337 Appendectomy 338-343 Minor Small and Large Bowel Procedures 344-346 Anal and Stomal Procedures 347-349 Hernia Procedures 350-355 Other Digestive System O.R. Procedures 356-358

Appendix E: Operating Room Procedures and Procedure Code/MS-DRG Index Tables of Procedure Code Combinations Required for Specific MS-DRGS Pacemaker Lead/Device Reference Table Cardioverter-Defibrillator Lead(s)/Generator Reference Table Kidney/Pancreas Transplant Reference Table Intracardiac Lead/Device Reference Table Heart Assist System Table Major Brain Device Implant Table Neurotransmitter/Neurostimulator Table

Appendix E: Intracardiac Lead Table

Appendix E: O.R. Procedures and Procedure Code/MS-DRG Index OHB8XZZ, Excision, Skin, Buttocks 0HB8XZZ 01 040-042 Peripheral and Cranial Nerve and Other Nervous System Procedures 0HB8XZZ 02 Extraocular Procedures Except Orbit 0HB8XZZ 03 133-134 Other Ear, Nose, Mouth and Throat O.R. Procedures 0HB8XZZ 04 166-168 Other Respiratory System O.R. Procedures 0HB8XZZ 05 Other Circulatory O.R. Procedures 0HB8XZZ 06 356-358 Other Digestive System O.R. Procedures 0HB8XZZ 07 423-425 Other Hepatobiliary or Pancreas O.R. Procedures 0HB8XZZ 08 463-465 Wound Debridement and Skin Graft Except Hand, for Musculoskeletal and Connective Tissue Disorders 0HB8XZZ 09 570-572 Skin Debridement 0HB8XZZ 10 622-624 Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders 0HB8XZZ 11 673-675 Other Kidney and Urinary Tract Procedures 0HB8XZZ 12 715-718 Other Male Reproductive System O.R. Procedures 0HB8XZZ 13 749-750 Other Female Reproductive System O.R. Procedures 0HB8XZZ 16 802-804 Other O.R. Procedures of the Blood and Blood Forming Organs 0HB8XZZ 21 901-903 Wound Debridements for Injuries 0HB8XZZ 22 927 Extensive Burns or Full Thickness Burns with MV 96+Hours 0HB8XZZ 22 928-929 Full Thickness Burns 0HB8XZZ 24 957-959 Other O.R. Procedures for Multiple Significant Trauma

MS-DRG Manual Table of Contents

Appendix I: Hospital Acquired Conditions (HACS) List

Impact of MS-DRG Conversion to ICD-10-CM/PCS on DRG Assignment Recoded FY2010 MedPAR data into ICD-10-CM/PCS using GEMS and many project specific rules to ensure correctness of code mapping and regrouped them using v30.0 ICD-10 MS-DRG Grouper 99% of cases assigned to same MS-DRG 1% of cases assigned to a different MS-DRG 45% to higher weighted MS-DRGs 75% of shifts to higher weighted MS-DRGs due to gaining a CC or MCC 55% to lower weighted MS-DRGs 40% of shifts to lower weighted MS-DRGs due to losing a CC or MCC

Top MS-DRGs with Positive Shifts DRG 011, Tracheostomy for face, mouth and neck dx w/ MCC 037, Extracranial procedures w MCC 066, Intracranial hemorrhage or cerebral infarction w/o CC/MCC 812, Red blood cell disorders w/mcc Reason for Shift Tracheostomy coded separately from radical larngectomy in ICD-10- CM so more cases with MCC moving into Trach MS-DRGs Shift of more cases into MS-DRG because of changes in MCC exclusion lists. Cases shifted out of the w/o CC or MCC to higher weighted MS-DRGs with CCs. Mostly cases with multiple CVA codes including CVAs that mapped to ICD-9-CM code 433.81 which is not excluded as a CC with other CVA codes. ICD-10-CM coding guidelines put malignancy first and anemia second. MS-DRG lost cases to other higher weighted cancer MS-DRGs

Top MS-DRGs with Negative Shifts MS-DRG 981, Extensive O.R. procedures unrelated to PDX with MCC 391, Esophagitis, gastroenteritis & misc. digestive disorders with MCC Reason for Shift Most of the shifting is due to loss of an MCC About 90% of the weight change is due to ICD-10-CM code K22.8, Other diseases of esophagus being mapped to 530.89 in the reimbursement mapping. It goes to a lower weighted MS-DRG. 885, Psychoses 296.20, Major depression is mapped to F32.9 which is classified to lower weighted MS-DRG 881. 191, COPD with CC Due to reclassification of COPD and asthma codes and the new combinations not counting as CCs for each other as often. 974, HIV with major related condition with MCC In ICD-10-CM sepsis codes in category A41, but mapped to 995.51 which is excluded as MCC for MS-DRG 974. 292, Heart failure and shock with CC All cases with CC Malignant hypertension, mapped to I10, Essential hypertension which is not a CC.

References Mills, R.E., Butler, R.R., Averill, R.F., McCullough, E.C., Bao, M.Z., Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments. 3M Health Information Systems, Wallingford CT. Mills, Ron. Estimating the Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments. Center for Medicare and Medicaid Services, Agenda: ICD-9-CM Coordination and Maintenance Committee, March 5, 2013. Accessed: April 23, 2013 http://cms.gov/medicare/coding/icd9providerdiagnosticcodes/meetings.html Centers for Medicare and Medicaid Services: Draft ICD-10-CM/PCS DRGv30 definitions manual. Modified : February 13, 2013. Accessed: April 23, 2013 http://www.cms.gov/icd10manual/version30-fullcodecms/p0001.html Converting MS-DRGs 26.0 to ICD-10-CM and ICD-10-PCS Updated 2/25/13 with new impact article. Accessed: April 23, 2013 http://cms.gov/medicare/coding/icd10/icd-10-ms-drg-conversion- Project.html 2013 General Equivalence Mappings Diagnosis Codes and Guide. Accessed: April 23, 2013. http://cms.gov/medicare/coding/icd10/2013-icd-10-cm-and-gems.html 2013 General Equivalence Mappings Procedure Codes and Guide. Accessed: April 23, 2013. http://cms.gov/medicare/coding/icd10/2013-icd-10-pcs-gems.html 2013 Reimbursement Mappings Diagnosis Codes and Guide. Accessed: April 23, 2013. http://cms.gov/medicare/coding/icd10/2013-icd-10-cm-and-gems.html 2013 Reimbursement Mappings Procedure Codes and Guide. Accessed: April 23, 2013. http://cms.gov/medicare/coding/icd10/2013-icd-10-pcs-gems.html

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