DRG Expert A comprehensive guidebook to the MS-DRG classification system Changes effective with discharges on or after October 1, 2008 2009 25th Edition
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... 24 MDC 3 Diseases And Disorders Of The Ear, Nose, Mouth And Throat... 29 MDC 4 Diseases And Disorders Of The Respiratory System... 36 MDC 5 Diseases And Disorders Of The Circulatory System... 42 MDC 6 Diseases And Disorders Of The Digestive System... 58 MDC 7 Diseases And Disorders Of The Hepatobiliary System And Pancreas... 68 MDC 8 Diseases And Disorders Of The Musculoskeletal System And Connective Tissue... 72 MDC 9 Diseases And Disorders Of The Skin, Subcutaneous Tissue And Breast... 89 MDC 10 Endocrine, Nutritional And Metabolic Diseases And Disorders... 97 MDC 11 Diseases And Disorders Of The Kidney And Urinary Tract... 102 MDC 12 Diseases And Disorders Of The Male Reproductive System... 108 MDC 13 Diseases And Disorders Of The Female Reproductive System... 112 MDC 14 Pregnancy, Childbirth And The Puerperium... 119 MDC 15 Newborns And Other Neonates With Conditions Originating In The Perinatal Period... 143 MDC 16 Diseases And Disorders Of The Blood And Blood-Forming Organs And Immunological Disorders... 155 MDC 17 Myeloproliferative Diseases And Disorders And Poorly Differentiated Neoplasms...157 MDC 18 Infectious And Parasitic Diseases...163 MDC 19 Mental Diseases And Disorders...167 MDC 20 Alcohol/Drug Use And Alcohol/Drug-Induced Organic Mental Disorders...169 MDC 21 Injury, Poisoning And Toxic Effects Of Drugs...170 MDC 22 Burns...185 MDC 23 Factors Influencing Health Status And Other Contacts With Health Services...190 MDC 24 Multiple Significant Trauma...193 MDC 25 Human Immunodeficiency Virus Infections...205 DRGs Associated with All MDCs...208 Alphabetic Index to Diseases...213 Numeric Index to Diseases...275 Alphabetic Index to Procedures...337 Numeric Index to Procedures...359 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
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 8.2920 Principal Diagnosis 094.87 Syphilitic ruptured cerebral aneurysm 430 Subarachnoid hemorrhage 431 Intracerebral hemorrhage 432* Other and unspecified intracranial hemorrhage Operating Room Procedures 02.13 Ligation of meningeal vessel 38.01 Incision of intracranial 38.11 Endarterectomy of intracranial 38.31 Resection of intracranial with anastomosis 38.41 Resection of intracranial with replacement 38.51 Ligation and stripping of varicose veins of intracranial 38.61 Other excision of intracranial 38.81 Other surgical occlusion of intracranial 39.28 Extracranial-intracranial (EC-IC) vascular bypass 39.51 Clipping of aneurysm 39.52 Other repair of aneurysm 39.53 Repair of arteriovenous fistula 39.72 Endovascular repair or occlusion of head and neck 39.79 Other endovascular repair (of aneurysm) of other DRG y 021 Diagnosis of Hemorrhage s with y CC GMLOS 13.7 AMLOS 15.5 RW 6.3596 4 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 4.1535 4 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 5.0584 Operating Room Procedures 00.62 Percutaneous angioplasty or atherectomy of intracranial vessel(s) 01.12 Open biopsy of cerebral meninges 01.14 Open biopsy of brain 01.15 Biopsy of skull 01.18 Other diagnostic procedures on brain and cerebral meninges 01.19 Other diagnostic procedures on skull 01.21 Incision and drainage of cranial sinus 01.22 Removal of intracranial neurostimulator lead(s) 01.23 Reopening of craniotomy site 01.24 Other craniotomy 01.25 Other craniectomy 01.28 Placement of intracerebral catheter(s) via burr hole(s) 01.31 Incision of cerebral meninges 01.32 Lobotomy and tractotomy 01.39 Other incision of brain 01.41 Operations on thalamus 01.42 Operations on globus pallidus 01.51 Excision of lesion or tissue of cerebral meninges 01.52 Hemispherectomy 01.53 Lobectomy of brain 01.59 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 02.91 Lysis of cortical adhesions 02.92 Repair of brain 02.93 Implantation or replacement of intracranial neurostimulator lead(s) 02.94 Insertion or replacement of skull tongs or halo traction device 02.99 Other operations on skull, brain, and cerebral meninges 04.01 Excision of acoustic neuroma 04.41 Decompression of trigeminal nerve root 07.13 Biopsy of pituitary gland, transfrontal approach 07.14 Biopsy of pituitary gland, transsphenoidal approach 07.15 Biopsy of pituitary gland, unspecified approach 07.17 Biopsy of pineal gland 07.5* Operations on pineal gland 07.6* Hypophysectomy 07.7* Other operations on hypophysis 29.92 Division of glossopharyngeal nerve 38.01 Incision of intracranial 38.11 Endarterectomy of intracranial 38.31 Resection of intracranial with anastomosis 38.41 Resection of intracranial with replacement 38.51 Ligation and stripping of varicose veins of intracranial 38.61 Other excision of intracranial 38.81 Other surgical occlusion of intracranial 39.28 Extracranial-intracranial (EC-IC) vascular bypass 39.51 Clipping of aneurysm 39.52 Other repair of aneurysm 39.53 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 10/01/2008 09/30/2009 5
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
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 412.529 in conjunction with 412.503). * 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 1 1 1 Heart transplant or implant of heart assist system w MCC 0 0.0000 0.0 0.0 2 1 Heart transplant or implant of heart assist system w/o MCC 0 0.0000 0.0 0.0 3 3 ECMO or trach w MV 96+ hrs or PDX exc face, mouth & neck w maj O.R. 291 4.7718 66.9 55.8 4 4 Trach w MV 96+ hrs or PDX exc face, mouth & neck w/o maj O.R. 1211 3.0860 44.5 37.1 5 5 Liver transplant w MCC or intestinal transplant 0 0.0000 0.0 0.0 6 5 Liver transplant w/o MCC 0 0.0000 0.0 0.0 7 7 Lung transplant 0 0.0000 0.0 0.0 8 8 Simultaneous pancreas/kidney transplant 0 0.0000 0.0 0.0 9 9 Bone marrow transplant 0 1.2921 31.4 26.2 10 10 Pancreas transplant 0 0.0000 0.0 0.0 11 11 Tracheostomy for face,mouth & neck diagnoses w MCC 1 1.7960 38.2 31.8 12 11 Tracheostomy for face,mouth & neck diagnoses w CC 1 1.7960 38.2 31.8 13 11 Tracheostomy for face,mouth & neck diagnoses w/o 0 1.7960 38.2 31.8 20 20 Intracranial vascular procedures w PDX hemorrhage w MCC 0 1.7960 38.2 31.8 21 20 Intracranial vascular procedures w PDX hemorrhage w CC 0 1.7960 38.2 31.8 22 20 Intracranial vascular procedures w PDX hemorrhage w/o 0 1.7960 38.2 31.8 23 23 Craniotomy w major device implant or acute complex CNS PDX w MCC* 2 1.2921 31.4 26.2 24 23 Craniotomy w major device implant or acute complex CNS PDX w/o MCC* 1 1.2921 31.4 26.2 25 25 Craniotomy & endovascular intracranial procedures w MCC 2 1.7960 38.2 31.8 26 25 Craniotomy & endovascular intracranial procedures w CC 3 1.7960 38.2 31.8 27 25 Craniotomy & endovascular intracranial procedures w/o 1 0.8819 25.2 21.0 28 28 Spinal procedures w MCC 12 1.2921 31.4 26.2 29 28 Spinal procedures w CC 9 1.2921 31.4 26.2 30 28 Spinal procedures w/o 1 1.2921 31.4 26.2 31 31 Ventricular shunt procedures w MCC 5 1.7960 38.2 31.8 32 31 Ventricular shunt procedures w CC 1 1.7960 38.2 31.8 33 31 Ventricular shunt procedures w/o 0 1.7960 38.2 31.8 34 34 Carotid artery stent procedure w MCC 0 1.2921 31.4 26.2 35 34 Carotid artery stent procedurew CC 0 1.2921 31.4 26.2 36 34 Carotid artery stent procedure w/o 0 1.2921 31.4 26.2 37 37 Extracranial procedures w MCC 7 1.2921 31.4 26.2 38 37 Extracranial procedures w CC* 6 1.2921 31.4 26.2 39 37 Extracranial procedures w/o 0 1.2921 31.4 26.2 40 40 Periph & cranial nerve & other nerv syst proc w MCC 143 1.2796 34.8 29.0 41 40 Periph & cranial nerve & other nerv syst proc w CC 88 1.1156 34.2 28.5 42 40 Periph & cranial nerve & other nerv syst proc w/o * 6 1.1156 34.2 28.5 52 52 Spinal disorders & injuries w 84 1.0515 31.6 26.3 Appendix D MS-LTC-DRG Crosswalk 2008 Ingenix Appendix 77