Most Common DRG’s with Recommendations: # 4 DRG 193

As stated in yesterday’s coding tip, HIA reviewed over 50,000 inpatient records in 2019. We are counting down to the # 1 DRG change for HIA in 2019. Any guesses to what that would be?

#4 DRG with the most recommendations during HIA reviews

DRG 193—Simple pneumonia & pleurisy with MCC

The majority of the recommendations from DRG 193 (Simple pneumonia & pleurisy with MCC) were due to changes in the PDX (75% without query being needed). The most common findings were coding the pneumonia to a more specific bacterial pneumonia or aspiration and sepsis being reported as the PDX. The second most common reason for DRG changes from 193, is taking away the MCC (about 1/3 of these did require a query). The MCC’s were not clearly documented in many of the records that fell into the review and required queries to clarify the validity of the diagnoses (MCC). DRG 193 was reported accurately only 88.82% of the time based on records reviewed by HIA in 2019 (778 records reviewed).

ICD-10-CM code J18.9 -Pneumonia, unspecified organism, was the 6th most reported diagnosis with either additions, deletions and/or revisions during HIA inpatient coding reviews in 2019. This code was reported correctly only 86.28% of the time.

What can coders do to improve accuracy of DRG 193?

  • Review the medical record for further specificity of the type of pneumonia documented (specified bacteria or aspiration)
  • Clarify if the diagnosis of sepsis is also documented and supported in the record and if so determine if it was present on admission and should be sequenced as the PDX
  • Query anytime there is ambiguous or conflicted documentation prior to coding finalization
  • Review the operative notes for details of “lung” being biopsied during bronchoscopies. There were a few changes based on the PCS code being changed from bronchus to lung
  • Was acute respiratory failure also present? If so, is the focus of the admission?
  • Did the patient present with more than one potential PDX? If so, review the medical record to determine if equal treatment was given or if one of the diagnosis was the focus of the admission. There were 9 records where congestive heart failure was sequenced as the PDX during these reviews
  • Verify if the patient has a lung transplant and if so, is the pneumonia in the transplanted lung
  • 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.
  • Bottom line is to protect the DRG at final coding by making sure that it is correct, and there will be no question after final billing about the ICD-10-CM and 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.

Be on the lookout for the #3 most common DRG recommendation for 2019.

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

ICD-10-CM and 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.

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