Part 8: Most Common DRG’s with Recommendations – DRG 981/982

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. 

#8: DRG 981/982—Extensive O.R. procedures unrelated to principal diagnosis with MCC (CC)

DRG 981 (Extensive O.R Procedures unrelated to principal diagnosis with MCC) was the number 8 most common DRG with recommendations from HIA in 2021. DRG 982 (Extensive O.R. procedures unrelated to principal diagnosis with CC) was close behind. Due to this, we will include in this tidbit.

Records reviewed: 532
DRG recommended changes: 123
Accuracy of DRG 981/982: 73.96%

It seems odd to see this DRG as one of the top 10 with recommendations, but I guess that does make sense. There is still confusion on when this DRG is appropriate. Oftentimes, it is due to an inpatient admission from the outpatient service. However, for the recommendations, we saw that the recommendations made were mostly due to PDX and PCS coding.

Reasons for DRG 981/982 recommendations:

The majority of the recommendation from DRG 981 (Extensive O.R Procedures unrelated to principal diagnosis with MCC) and 982 (Extensive O.R Procedures unrelated to principal diagnosis with CC) were due to PDX (very few required physician query) and addition, revision, or deletion of PCS code (only a couple required physician query). Out of the total 122 DRG recommendations made, 107 were for PDX or PCS, and only 13 required a query.

• The most common reason for DRG recommendations was to re-sequence or add a new PDX. Only a few of these required a physician query for clarification. There was no trend to the recommended DRG since it would depend on the PDX/PCS grouping. What this means is that there was sufficient documentation in the medical record to support the new PDX. Remember, when coding, if there is more than one condition responsible for the admission, once a surgical procedure is performed they may no longer be considered “equal.” In these cases, a coder should select for the PDX, the condition that required a surgical procedure. Of course this is not the case with outpatient to inpatient admissions or conditions that develop after inpatient admission that may require surgical treatment.
• The next most common reason for change was recommendations to add, delete or specify a PCS code.  The majority did not require a physician query to support the change. What this means is that there was documentation in the medical record to support the appropriate PCS code. A lot of times, the PDX would be correct, but once the PCS code is changed the account groups to a surgical DRG that is related to the PDX.
• There were several records that either had the MCC removed from the account or had an MCC added (to the DRG 982 records) that changed the DRG. The majority of these did require a physician query.

What can coders do to improve the accuracy of reporting DRG’s 981/982?

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:

• Verify the reasons for the patient’s admission. When multiple conditions necessitate the admission, and equally meet the criteria for principal diagnosis, any of these may be sequenced first. The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
• Code all procedures that are surgical in nature to the highest level of specificity. If the procedure is new or there is question about how to code, always reach out for help to ensure that the most appropriate PCS code is reported.
• When coding and the record falls into one of these DRG’s, take a second look. Some facilities do have a policy where these are looked at by another coder or supervisor before finalizing the records. If you don’t have this in place, but are having changes in these DRG’s, it would be a great place to start.
• 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.
• If there is a question about a diagnosis or procedure 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.
• 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.