Most Common DRG’s with Recommendations: # 2 DRG 872

We’re now at the second most common DRG with recommendations by HIA for 2019. Just to recap, HIA reviewed over 50,000 inpatient records in 2019. We are counting down to # 1.

#2 DRG with the most recommendations during HIA reviews

DRG 872—Septicemia or severe sepsis w/o mechanical ventilation >96 hours w/o MCC

Sepsis is and will most likely always be a troubled area for coders. As stated in the sepsis series from November, there are many different criteria being used to diagnose sepsis. That is one of the reasons that it is so difficult to code. However, when we dig in deep to the reasons for the changes in 2019, there is something besides sepsis criteria that is resulting in the recommendations.

The majority of the recommendations from DRG 872 (Septicemia or severe sepsis w/o mechanical ventilation >96 hours w/o MCC) were due to PDX selection. Many of these did require a physician query for clarification, but not all. It was about 50/50 on queries for PDX clarification. Here are the DRG’s that were recommended for PDX selection (only the ones with many recommendations):

• DRG 862—Postoperative & Post-traumatic infections with MCC
• DRG 919—Complications of treatment with MCC
• DRG 698—Other kidney & urinary tract diagnoses with MCC
• DRG 602—Cellulitis with MCC
• DRG 689—Kidney and urinary tract infections with MCC
• DRG 864—Fever and inflammatory conditions

There are many other recommendations that went to different DRG’s based on PDX change, but these were all a single recommendation or so per DRG.

The next most common recommendation was for addition of MCC to the account. The majority of these did NOT require a physician query for clarification in order to add. These all resulted in a new DRG of 871—Septicemia or severe sepsis w/o mechanical ventilation >96 hours with MCC.

The final reason for recommendations made to records reviewed with DRG 872 was the addition or revision of an ICD-10-PCS code. All of these were recommended to surgical DRG’s 853—Infectious and parasitic diseases with O.R. procedure with MCC and 854—Infectious and parasitic diseases with O.R. procedure with CC. The majority of these recommendations did not require a physician query for clarification.

What can coders do to improve accuracy of DRG 872?

• Review and verify that the diagnosis of sepsis is accurate at the time of final coding
• Look for causes of sepsis and if there is a link to a device or other complication
• Is sepsis supported? Is a query necessary to clearly document the diagnosis?
• Is the diagnosis of sepsis dropped after admission without clearly ruling out the condition? Query when necessary.
• Are there any chapter specific guidelines that should be followed? There were a few recommendations that went to Chapter 15 (Pregnancy, Childbirth, and the Puerperium) codes for the PDX.
• Does the discharge summary contradict or conflict with the rest of the medical record documentation? When this occurs, it is often necessary to query for clarification.
• Are there clinical indicators to support the diagnosis of sepsis? If not, a query may be necessary.
• Review the medical record for any and all procedures that were performed. If there is anything in the operative note that needs to be clarified that should be completed at the time of coding. Depth of debridement is a very common reason for change based on ICD-10-PCS codes.
• Review the medical record for any past or current conditions and complications. If the documentation is not clear, a query may be needed.

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 (see the 5 part Sepsis Series published November 2019). The E-Book on this series can be downloaded on our website here: https://www.hiacode.com/blog/resources/

Be on the lookout tomorrow for the #1 most common DRG recommendation for 2019.

Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P

References
ICD-10-CM Official Guidelines for Coding and Reporting FY 2020
ICD-10-PCS Official Guidelines for Coding and Reporting FY 2020

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.