EC TWINNING PROJECT Development of National Coding Standards within the Czech DRG System CZ2005/IB/SO/03 Australian Refined Diagnosis Related Groups (ARDRGs) & the Definition Manual 1
Introduction The propose of this presentation is to discuss Australian refined Diagnosis related group (ARDRG) grouping system and the definition manual We will cover What they are? Where they have come from? How they are assigned? What is a Group? A Group or Diagnosis Related Group (DRG) is a group of patients that are clinically similar have similar resource usage (i.e. they cost the same) The groups are designed so that they are different to each other (I.e. Mutually exclusive). Grouping systems are often referred to a Secondary Classifications. 2
Grouping At is simplest level, a grouping scheme sorts data so that everything is stored in a like with like manner. Grouping Decisions on grouping are based on statistical analysis of the differences between the groups and the sameness of groups. The differences are identified by criteria such as Diagnosis/procedure Age 3
Different Groupers There are different types of groupers used internationally. HCFA DRG HCFA stands for Health Care Financial Authority Replaced with CMS (Centres for Medicare & Medicaid Services) (V20.0) And now replaced again by MSDRG (V25.0) Irish CASEMIX system used versions 9, 12 and 16. Implemented in Ireland using the 3M software. Different Groupers IRDRG International Refined Diagnosis Related Grouper Not used in Ireland. ANDRG Australian National Diagnosis Related Grouper Not used in Ireland Predecessor of the ARDRG grouper. ARDRG Australian Refined Diagnosis Related Grouper Used in Ireland Versions 5.0 and 5.1 have been used. Implemented in Ireland using the Laeta Software 4
DRGs in Ireland Currently we are using Australian Refined Diagnosis Related Groups (ARDRGs) The version in use is 5.1. This grouping scheme relates to the ICD-10-AM (4ed) coding classification system. Earlier versions of ARDRG relate to earlier coding schemes. I.e. Version 4.1 and relates to the ICD-10-AM (3ed) Version 5.0 was used for 2003 & 2004 data in Ireland. This was used with ICD-9-CM coded data using a process called Mapping. ARDRG Assignment Overview DRG assignment all activity collated and categorised into DRGs. Assignment based on the concept of Like with like Assignment is split into Medical/Surgical and Other Assignment can be further Sub-Classified 5
ADRGs Adjacent DRGs (ADRGs) are a related CASEMIX classification. It consists of the first three characters of an ARDRG code. Examples include ADRG ARDRG C63 Oth er Disorders of th e Eye C63A Oth er Disorders of th e Eye W CC C63B Oth er Disorders of th e Eye W/O CC G46 Complex Gastroscopy G46A Complex Gastroscopy W Catastroph ic or Severe CC G46B Complex Gastroscopy W/O Catastroph ic or Sever e CC G46C Complex Gastroscopy, Sameday I04 Knee Replacemen t and Reattach men t I04Z Kn ee Replacement and Reattach men t ARDRG Code Example J67A Minor Skin Disorder The first character is either a letter indicating the broad group of the ARDRG or 9 indicating an error ARDRG. The final character is either A to D indicating a levels of complexity ( A being most complex) or Z indicating that there is no complexity split The ADRG J67A The middle two characters are numbers indicating whether the code is Surgical, Medical or Other. They are divided up as follows Surgical Other Medical 00 20 39 40 59 60 80 99 6
How are patients assigned to DRGs? Every patient is assigned to one and only one DRG Assignment based on complex statistical algorithm using the following six items of information Age Sex Principal Diagnosis Secondary Diagnoses Procedures Performed Discharge status Major Diagnostic Categories Major Diagnostic Categories (MDC) are a further aggregation of the DRGs. The values are broadly related to body area. We are currently using 24 MDCs. MDCs are generated as part of the grouping process This means that different groupers will assign MDCs in different ways. Hence we must be carefully comparing MDCs from different groupers. 7
Major Diagnostic Categories MDC Description 0 Unassigna ble to MDC 1 Disea ses & Disorders of the Nervous System 2 Disea ses & Disorders of the Eye MDC Description 3 Diseases & Disorders of the Ear, Nose, Mouth & Throat 12 Diseases & Disorders of the Male Reprodu ctive System 4 Disea ses & Disorders of th e Respira tory System 13 Diseases & Disorders of the Female Reprodu ctive System 5 Diseases & Disorders of the Circulatory System 14 Pregnancy, Ch ildbirth & the Pu erperiu m 6 Disea ses & Disorders of the Digestive System 15 Newborns & Other Neonates 7 Diseases & Disorders of the Hepa tobiliary System & Pancrea s 16 Diseases & Disorders of Blood, Blood Formin g Organ s, Immun ological Disorders 8 Disea ses & Disorders of the Musculoskeletal System & Connective Tissue 17 Neoplastic Disorders (H aematological & Solid Neoplasms) 9 Diseases & Disorders of the Skin, Subcutaneous Tissue & Brea st 18 In fectiou s & Parasitic Diseases, Systemic or Unspecified Sites 10 Endocrine, Nutritional & Metabolic Disea ses & Disorders 19 Men tal Diseases & Disorders 11 Diseases & Disorders of the Kidney & Urinary Tra ct 20 Alcohol/Drug Use & Alcohol/Dru g Induced Organic Mental Disorders 21 Injuries, Poison in gs & Toxic Effects of Drugs 22 Bu rn s 23 Factors Influencin g H ealth Statu s & Other Contacts with H ealth Services ARDRG : Origins ARDRG history is linked with coding classification systems. ARDRGs where created in Australia The Australians began with the HCFA DRG system and ICD-9-CM In 1992, ANDRG V1.0 was released. This used ICD-9-CM (Oct 1991) This was updated in 1993 and 1994 when the coding scheme was changed. 8
ARDRG : Origins In 1995, The Australians changed the ICD-9- CM coding scheme and created an Australian version. This led to the creation of ANDRG V3.0 In 1996 the second edition of the Australian modified ICD-9-CM was released. Two versions of the grouper were released over the two years (V3.1 & V3.2 ) This was followed by ARDRG v4.0 in July 1998. ARDRG : Origins In July 1998, Australia adopted ICD-10-AM This version was labelled the 1 St Edition. ARDRG V4.1 was released in December The Australians adopted a two year cycle for updating the coding and grouper systems ICD-10-AM 2 nd Edition July 2000 ARDRG V4.2 Dec 2000 ICD-10-AM 3 rd Edition July 2002 ARDRG V5.0 Sep 2002 ICD-10-AM 4 th Edition July 2004 ARDRG V5.1 Sep 2004 9
ARDRG Definition Manual The Australian refined diagnosis related group (ARDRG) definitional manual comes in three parts The manual contains Overview of ARDRGs History of ARDRGs Common Abbreviations Grouping explanation ARDRG Definition Manual Flow charts for each MDC Decision tables for each decision in the grouping Appendix information used in grouping. The Manual also contains a CD holding various appendix tables The CD also stores the CCL (Complications and Co-morbidity levels) calculator. 10
The Irish Situation In Ireland, the Windows HIPE data entry system program will do the grouping as part of an internal process. It uses a third party grouper provided by Laeta PTY of Australia to determine the groups for the cases. The steps There are seven steps needed for grouping a case to ARDRG. 1. Determine the MDC of the case. 2. Examine if the case qualifies as a premdc case. 3. Determine the Surgical/Medical/Other partition. 4. Obtain the ADRG of the case. 5. Identify the Complications and Co-morbidity levels (CCL) of the diagnoses 6. Determine the Patient Clinical Complexity level (PCCL) of the case. 7. Assign the ARDRG. 11
The steps (detail) Step 2 deals with the fact that a series of nine high cost Special case ADRGs are processed separately This can lead to the overruling of the initial MDC assignment. Steps 6 and 7 are used to determine complexity splits and these are not always required as Some ARDRGs do not have complexity splits Other ARDRGs rely on other factors for complexity splits (Age etc.) The tools The main tools in the assignment of ARDRGs are The ARDRG definition manuals Flow Charts Lookup Tables Appendices The CCL calculator software 12
The Flow Charts Lookup Tables 13
CCL calculator The Complications and Co-morbidity level (CCL) calculator is invaluable for the determining the CCLs of the diagnoses and thus the PCCL of the patient. Step 0 The real first step is where the Grouper performs data checks on the data. These checks are essentially data validation checks to determine if there are any inconsistencies in the data. In Ireland, most (all?) of these validation checks are carried out by the data entry software. If a problem arises the case is assigned to an error ARDRG. 14
ARDRG grouping Step 1 MDC assignment The first step is to assign the MDC to the case. This is done by examining the principal diagnosis and using the tables found in Appendix A (from page 5 onwards). The table is searched for the PDX and the MDC and likely medical ARDRGS are listed. If the PDX is not found then the MDC is set to 00 and the ARDRG is set to 960Z ungroupable ARDRG grouping Step 1 MDC assignment 15
Step 2 PreMDCs The second step is to examine the case and determine if it falls into one of nine high cost ADRGs. The range of areas include Transplant DRGs, newborns and neonates, HIV patients, Multiple Traumas established paraplegia or quadriplegia. Step 2 PreMDCs Decisions on whether a case falls into a PreMDC are based on a series of flow charts on pages 33-35 (Vol 1) and their associated lookup tables. When a case is in the PreMDC category, the MDC and ARDRGs found in step 1 may be overruled. 16
Step 3 MDC Partition The next step is to determine if the case is a Surgical, Medical or Other case. Decisions on these types of cases are based on the presence or absence of operating room (OR) procedures. A case is a Surgical case if it has at least one OR procedure. A case is an Other case if it has no OR Procedures but does have procedures significant to the case. A case is a Medical case otherwise. Step 3 MDC Partition To determine the partition, we use Appendix B (Vol 3) This lists, for each procedure, the MDC and likely ARDRGs Where the symbol appears after a procedure code, this indicates that the procedure code is a non OR procedure code. The MDC is chosen to match the one found in steps 1 and 2. If a match cannot be found the case is assigned an error DRG. 17
Step 3 MDC Partition Step 4 ADRG Assignment The next step is to assign the ADRG. Assignment of ADRG is performed using the flow chart and lookup tables of the chosen MDC. The ADRG are examined in the order they appear in the flow chart. The Surgical ADRGs appear first. These are sorted by decreasing resource consumption. The Other ADRGs appear next. These are also sorted by resource consumption. The Medical ADRGs appear at the end of each flow chart and these are often not sorted. 18
Step 4 ADRG Assignment Consider the following example Step 4 ADRG Assignment Note that at this stage it may be possible to assign the ARDRG without performing steps 5 and 6. There may not be a complexity split and therefore the ARDRG is simply the ADRG with a Z at the end. The complexity may be dependant on other factors other than PCCL. 19
Step 5 CCL determination The next step is to determine the complication and comorbidity level (CCL) for each secondary diagnosis. This is done using the CCL calculator found on the ARDRG CD which accompanies the definition manual. Step 5 CCL determination Ensure that the version is set to 5.1 Enter the secondary diagnoses here Enter the chosen ADRG at this point. This was found in step 4 Click on Calculate to get the CCL The details of the CCL will appear here. 20
Step 6 PCCL Determination The penultimate step is to determine the Patient Clinical Complexity Level. This is determined using the list of CCLs and using the following rules The PCCL of a case with no secondary diagnoses is 0. We do not need to consider a CCL for principal diagnosis unless there is some other factor (such as gender) If a diagnosis is repeated, the CCL of the second diagnosis is set to 0. Step 6 PCCL Determination Examine each of the secondary diagnosis in turn to determine if they are on the exclusion list of a previous diagnosis. If a diagnosis is excluded then the CCL is set to 0. Re-Order the CCLs in reducing order and re-check the exclusions. Determine the PCCL using the PCCL table. 21
Step 6 PCCL Determination Some notes on this process An example of the PCCL table is shown below PCCL CCL1 CCL2 CCL3 CCL4 CCL5 CCL6 CCL7 CCL8 CCL9 CCL10 4 4 3 4 4 2 4 4 1 1 4 3 3 4 3 2 2 4 3 2 1 1 4 2 2 2 2 4 2 2 2 1 1 1 3 4 3 4 1 3 3 3 3 2 3 3 2 1 3 2 2 3 2 2 2 1 1 3 2 2 2 3 2 2 1 1 1 1 1 1 1 1 3 2 1 1 1 1 1 1 1 1 1 3 2 1 3 1 1 1 1 1 2 2 2 1 1 1 1 Step 6 PCCL Determination The exclusion process operates in the following manner The primary diagnosis is checked to see if it is on the exclusion list of the first secondary diagnosis. The primary and first secondary diagnosis are checked to see if they are on the exclusion list of the second secondary diagnosis Etc. The exclusion lists are stored in a file on the CD called CCEXCL.TXT 22
Step 7 ARDRG Assignment The final stage is to use the flow charts from step 4 to determine the ARDRG. If the PCCL is used then the decision based on one of the following. PCCL Description CC Mod CC Cat or Sev CC Sev CC Cat CC 0 No CC effect 1 Minor CC effect 2 Moderate CC 3 Severe CC 4 Catastrophic CC Example 1 Consider the following patient Diagnoses Procedure K359 Acute appendicitis, unspecified 30571-00 Appendicectomy N390 Urinary tract infection, site not specified 92514-99 General anaesthesia, ASA 99 A498 Z8643 Other bacterial infections of unspecified Personal history of tobacco use disorder Moving through the steps, Step 1 MDC assignment Use the Appendix A to search for K359. This is found on page 37. The MDC is 06. The ARDRGs are G45A, G45B, G70A, G70B. 23
Example 1 Step 2 PreMDC The case does not fall into the PreMDC category. Step 3 MDC partitioning. The procedure 30571-00 is an OR procedure. The procedure 92514-99 is not an OR procedure. Hence this is a surgical case. MDC 06 is found and the ARDRG are G07A and G07B. Step 4 ADRG Assignment Consult the flow chart for MDC 06 (found on page 203). G07 is chosen as the procedure code 30571-00 is found in the lookup table on page 217. Example 1 Step 5 CCL determination The CCL calculator is used to determine the PCCL for each diagnosis. The CCL for N390 is 3. The CCLs for the other diagnosis are 0. Step 6 PCCL determination The CCL of 3 is used to lookup the PCCL table PCCL 4 CCL1 3 CCL2 2 CCL3 2 CCL4 CCL5 CCL6 CCL7 CCL8 CCL9 CCL10 4 3 2 1 1 4 2 2 2 2 4 2 2 2 1 1 1 3 4 3 4 1 3 3 3 3 2 3 3 2 1 3 2 2 The PCCL is found to be 3. 24
Example 1 Step 7 Assign ARDRG Use the flowchart from Step 4 to decide on G07A. Example 2 Consider the following patient Diagnoses Procedure K823 Fistula of gallbladder 30443-00 Cholecystectomy K564 Other impaction of intestine 30375-03 Enterotomy of small intestine K565 Intestinal adhesions [bands] with obstruction 92514-39 General anaesthesia, ASA 39 I219 Acute myocardial infarction, unspecified 13706-02 Transfusion of packed cells I501 Left ventricular failure 95550-03 Allied health intervtn, physiotherapy K922 E780 Z951 Gastrointestinal haemorrhage, unspecified Pure hypercholesterolaemia Presence of aortocoronary bypass graft 25
Step 1 Example 2 Look up appendix A (page 39) This gives us Step 2 MDC 07. ADRGS H64A, H64B. The case is not part of premdc. See Handout Step 3 Example 2 Lookup appendix B (pages 125, 129, 222 and 131) This gives us 30443-00 MDC 07 H07A, H07B MDC 17 R01A, R01B, R02A, R02B MDC 21 W03Z, X06A, X06B 30375-03 MDC 06 G05A, G05B MDC 17 R01A, R01B, R02A, R02B MDC 21 W03Z, X06A, X06B 92514-39 MDC 05 F42B 13706-02 MDC 15 P65C, P66C, P67C 95550-03 Not listed 26
Example 2 Hence we are dealing with an OR case. MDC 07 is common between Step1 and Step2. Chosen ARDRGs H07A and H07B. Note that we ignore the ARDRGs H64A and H64B as these are medical DRGs. Example 2 Step 4 Use the MDC 07 Flow chart pages 239-241. Examine each step one at a time and assign based on the order they are encountered. This gives us ADRG is H07. It is necessary to calculate the CCLs and PCCL as ARDRG assignment is based on the PCCL. 27
Step 5 Example 2 Determine the CCL for each diagnosis This gives us K823 K564 K565 I219 I501 K952 E780 Z591 Principal Diagnosis CCL=3 CCL=3 CCL=4 CCL=3 CCL=0 CCL=0 CCL=0 Example 2 Step 6 Determine the PCCL for the case. First we examine to CCLs to see if there are any excluded. This gives us K823 Principal Diagnosis K564 CCL=3 No Change K565 CCL=3 K564 is on the Excl list of K565 so CCL=0 I219 CCL=4 No Change I501 CCL=3 No Change K952 CCL=0 E780 CCL=0 Z591 CCL=0 28
Example 2 Now reorder the CCLs in decreasing order This gives us K823 Principal Diagnosis I219 CCL=4 K564 CCL=3 I501 CCL=3 K565 CCL=0 K952 CCL=0 E780 CCL=0 Z591 CCL=0 Example 2 Finally use the lookup table to see what PCCL value we get for 4, 3, 3 This leads to a PCCL of 4. Now we can assign the ARDRG to H07A. 29