Part 6: Most Common DRG’s with Recommendations – DRG 793/794

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. 

#6: DRG 793—Full term neonate with major problems

And DRG 794—Neonate with other significant problems

DRG 793 (Full term neonate with major problems) and DRG 794 (Neonate with other significant problems) are reported together for this tidbit since they were very close and very similar. The coding rules and guidelines for these two DRG’s are the same so we will look at these together.

Records reviewed: 1012
DRG recommended changes: 137
Accuracy of DRG 783/784: 85.28%

Thinking that coding a newborn record is easy is a thing of the past. These are, at times, very complex. The documentation is oftentimes unclear of the significance of the findings. Just because it is documented in the newborn record does not mean it should be coded. There are specific guidelines for this chapter of coding that must be followed. 

Reasons for DRG 793/794 recommendations:

The majority of the recommendations from DRG 793 (Full term neonate with major problems) and DRG 794 (Neonate with other significant problems) were due to addition, deletion, or revision of CC/MCC (only 6 out of 137 required physician query).

• The 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.
• The remainder of the reasons for DRG recommendations was to re-sequence or add a new PDX. Only a couple of these required a physician query for clarification.

What can coders do to improve the accuracy of reporting DRG 793/794?

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.
• Birth process vs. community acquired conditions should be clearly documented. If the condition is community acquired, Chapter 16 codes would not be used to report the condition. If the etiology is not clear, a query would be necessary.
• Follow the coding guidelines for additional secondary diagnosis with one addition. If the physician has documented that a condition has implications for future health care needs codes would be assigned. Even if the condition is not treated per se on this admission, if there is documentation that in the future this condition will require treatment it would be reported.
• Prematurity is only reported when documented by the physician.
• 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.

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.