Part 10: Most Common DRG’s with Recommendations – DRG 190

HIA reviewed almost 50,000 inpatient records and over half a million codes in 2021. We will look at the top DRG’s with recommendations and see what can be done to prevent DRG changes going forward. Each coding tidbit will contain some tips for coding within the DRG or diagnosis area.

#10: DRG 190—Chronic obstructive pulmonary disease with MCC

DRG 190 (Chronic obstructive pulmonary disease with MCC) was the number 10 most common DRG with recommendations from HIA in 2021.

Reviewed DRG : 311
DRG recommended changes: 62
Accuracy of DRG 190: 80.06%

More patients are diagnosed with COPD each year. It is the fourth leading cause of death in America and is expected to become the third leading cause within a decade. In 2021, it is estimated that 16 million adults have COPD, but it could be many more due to improper or undiagnosed disease. 

Reasons for COPD DRG recommendations:

The majority of the recommendation from DRG 190 (Chronic obstructive pulmonary disease with MCC) were due to changes in the PDX (only a few required physician query to support the recommendation).

• The most common PDX change was to re-sequence acute respiratory failure as the PDX or add the diagnosis of acute respiratory failure and sequence as the PDX (100% of these did not require a physician query for clarification). What this means is that all the supporting documentation in the for acute respiratory failure to be reported as the PDX was present at the time of original coding.
• The next most common reason for DRG recommendation was to DRG 191 (Chronic obstructive pulmonary disease with CC). All of these were for deletion of the MCC. Only a few of these required a physician query for clarification. What this means is that for most of the records, the documentation within the record did not support the MCC that had been reported. These were clearly documented as either ruled out or insignificant. The other few (4 records only), did require a physician query to clarify reporting of the MCC for some reason.
• The third most common reason for DRG 190 recommendations was to either re-sequence or add pneumonia as the PDX. Only one of these required a physician query for clarification. What this means is that the diagnosis of pneumonia was documented and supported within the medical record at the time of original coding.

What can coders do to improve the accuracy of reporting DRG 190?

The most important thing that a coder can do is to make sure that there are no questions that could be raised regarding any diagnosis that is used to calculate the DRG. Ask yourself these questions when coding:

• Coders should look for the diagnoses of pneumonia and acute respiratory failure when patients are admitted with COPD exacerbation. Oftentimes, it is one of those two conditions that inpatient treatment is needed for.
• If patient does have several respiratory issues on admission, it may be that one is the focus of admission over the others. There is no way to make a statement that would fit all coding scenarios and that is why each record must be reviewed in detail to determine which condition should be reported as the PDX.
• If acute respiratory failure is present on admission and documented as the focus and reason of the admission, it is very likely that this will be the PDX as this is the urgent/life threatening condition requiring admission. Again, all records must be reviewed in full to determine the appropriate PDX.
• Validate all MCC’s to ensure that documentation is in the medical record to support that these conditions should be reported. If there’s a chance that the condition may be ruled out, a query should be sent for clarification. When only 1 MCC is present on a record it is always best practice to double check to ensure that the condition meets reporting requirements as well as clinical validity so that it is protected in any audits.
• If there is a question about a diagnosis in the record that does impact the DRG, a query should be sent or coders should follow the procedure for their facility to escalate the record to a senior reviewer or physician liaison.
• Use the latest coding reference for sequencing COPD and pneumonia as this did change effective October 1, 2017 (instructional note changed from “use additional code to identify the infection” to “Code also to identify infection”). Even though this change was a couple of years ago, we still see coders following the older guidance.
• Query anytime there is ambiguous of conflicted documentation prior to coding finalization
• Bottom line is to protect the DRG at final coding by making sure that it is correct, and that there will be no question after final billing about the ICD-10-CM and/or ICD-10-PCS codes that were reported. Be sure and check for mechanical ventilation on these patients.

Coders should review the entire medical record to look for any conflicting documentation and clarify this prior to final coding. Clarification prior to final coding will decrease audit recommendations and denials. Remember, denials are costly to the facility with all the time that is spent trying to appeal.

If you’d like to read more on COPD, please visit HIA’s blog:

https://www.hiacode.com/education/coding-tip-what-is-copd/

https://www.hiacode.com/education/copd-pneumonia-sequencing-fy-2018/

https://www.hiacode.com/education/chronic-obstructive-pulmonary-disease-copd-and-asthma/

References
ICD-10-CM Official Guidelines for Coding and Reporting FY 2022
ICD-10-PCS Official Guidelines for Coding and Reporting FY 2022
ICD-10-CM/PCS Coding Clinic, Fourth Quarter 2017 Pages: 96 and 110
ICD-10-CM/PCS Coding Clinic, Fourth Quarter 2016 Pages: 147-149
ICD-10-CM/PCS Coding Clinic, Third Quarter 2016 Pages: 15-16
ICD-10-CM/PCS Coding Clinic, First Quarter 2017 Page: 24

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.