Part 5: Most Common DRG’s with Recommendations – DRG 193

This is the next most common DRG with recommendations found in HIA reviews in 2021. Just to recap, 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. 

#5: DRG 193—Simple pneumonia and pleurisy with MCC

DRG 193 (Simple pneumonia and pleurisy with MCC). DRG 193 seems to always be in the top 5 and a focus for denials. 

Records reviewed: 866
DRG recommended changes: 102
Accuracy of DRG 193: 88.22%

Pneumonia will most likely be one of the top reviews with recommendations forever. Or at least that is how it seems. Even back in the early 1980’s pneumonia DRG’s were troublesome.  

Reasons for DRG 193 recommendations:

The majority of the recommendations from DRG 193 (Simple pneumonia and pleurisy with MCC) were due addition, revision or re-sequencing of the PDX. Several did require a physician query to either support the PDX that was coded or to clarify a recommended PDX. When patients present with respiratory issues there is typically several issues going on at once. 

• The most common reason for change is adding a new, re-sequencing, or obtaining clarification of the assigned PDX. Several of these did require physician query to clarify the medical record documentation. The DRG’s that were most commonly recommended were 177 (Respiratory infections and inflammations with MCC), 189 (Pulmonary edema and respiratory failure), 190 (Chronic obstructive pulmonary disease with MCC), 291 (Heart failure and shock with MCC), and 871 (Septicemia or severe sepsis without MV >96 hours with MCC). If you notice, all of the recommended DRG’s are also DRG’s that are common for coding errors as well as focused on during reviews.
• The second most common reason for changes was for addition, deletion, or specificity of CC/MCC. There were several records that the CC/MCC was not clearly documented or supported. Almost all of these had the supporting documentation at the time of original coding for the CC/MCC.

What can coders do to improve the accuracy of reporting DRG 193?

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 or procedure that is used to calculate the DRG. Ask yourself these questions when coding:

• Validate all CC/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.
• 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.
• Verify that the assigned PDX has no room for questioning. If there is any documentation that contradicts or is unclear, the physician should be sent a query to clarify.
• Remember the official coding guideline that tells us that in the rare occasion when two or more diagnoses equally meet the criteria for PDX, either may be sequenced first. It is important to know the clinical picture of these patients so that coders can determine if treatment was equal or not. An example that comes to mind, and that we see often, is a patient admitted with shortness of breath and is thought to have both pneumonia and exacerbation of CHF. The patient is begun on IV fluids, IV antibiotics, oxygen at their home setting, and increase of their home Lasix from 20 mg to 40 mg twice daily p.o. In this case, even though both conditions were present on admission, and both were in an acute status, the treatment for the pneumonia is more resource intense than the treatment for the CHF. IV meds “trump” p,o. medication. For each record that has more than one possible PDX, especially in the respiratory system, it is best to walk each case through the coders mind to weigh out the treatment.

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.

References
ICD-10-CM Official Guidelines for Coding and Reporting FY 2022
ICD-10-PCS Official Guidelines for Coding and Reporting FY 2022

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.