DRG Shifts Caused By ICD-10-PCS Coding?

Tue, Mar 29, 2016 --

Coding Updates, ICD-10

Paracentesis and Arterial, ICD-10 Coding, coding Guidelines, ICD-10 Coding Culprits, Diagnostic and therapeutic abdominal paracentesis

The ICD-10 transition has been pretty smooth so far, but a few snags have occurred in the implementation. It turns out that in some cases, ICD-10-PCS procedure coding, even when correctly applied, can change a case’s Diagnostic Related Group (DRG) classification.

Inpatient coders on an AHIMA coding community message board discovered that when they reported arterial lines inserted for monitoring, they experienced a serious DRG shift. The culprit was a correctly chosen ICD-10-PCS code affecting the DRG grouper’s logic. This means that even if the line was just inserted at bedside to monitor a stroke patient’s blood pressure, the DRG grouping software read the correctly entered PCS code and kicked the DRG up to a high-risk surgical one. This DRG shift could cause reimbursement amounts to be artificially increased. When this sort of thing happened in ICD-9, it was usually due to a coding mistake. In ICD-10, however, this problem is apparently caused by bad logic in the coding structure of the DRG grouper software.

Quick Refresher — ICD-10-PCS Coding Concepts

ICD-10-PCS is used for inpatient coding of procedures using a seven-character alphanumeric codeset. Each digit represents an aspect of the procedure. The first character is for the Section, the broad area where the code is found, such as Medical and Surgical (0) or Obstetrics (1). The second character is for body system, meaning the general physiologic or anatomic region involved, such as gastrointestinal (D). The third character is for the root operation, describing the objective of the procedure. For example, in the GI system, the digit 1 represents “Bypass: Altering the route of passage of the contents of a tubular body part.” The fourth digit describes the body part or anatomical site, the fifth character the approach for the technique that was used to reach the procedure site. The sixth character indicates what type of device (that stays in the body, such as an implant) was used. The seventh character defines qualifiers or any additional attributes of the procedure.

Determining the Root Operation With the Third Character Is Key

In building the ICD-10-PCS code — and it truly is more an act of building than of picking — coders must closely read the physician’s operative report to be able to break the procedure into one of 31 root operations. Ranging from Alteration to Transplantation, picking the right choice of root operation can be tricky. For example, there’s a fine distinction between resection and excision in PCS. Excision means the physician used a sharp object to cut off a portion of a body part without replacing it, such as in a breast lumpectomy or liver biopsy. However, resection means that the physician cut out the entire body system without replacing it, such as in a total mastectomy or cholecystectomy.

Dealing With DRG Shifts

For those of us who deal mostly in outpatient and physician office coding, this information about ICD-10-PCS and DRGs can seem pretty arcane. But for hospital coders, DRG shifts can pose major threats to coding quality and reimbursement.

In their blog post over at ICD10 Monitor, Scot Nemchik, CCS, and Sabrina Yousfi, MBA, RHIA, CDIP, CCS, AHIMA-approved ICD-10 CM/PCS Trainer, addressed two ICD-10 coding culprits identified so far, dealing with reporting paracentesis and arterial lines. We already talked about arterial line insertion. With paracentesis, however, it turns out that the last digit in the PCS code is what caused the problem. The last digit in ICD-10-PCS codes, you remember, identifies “additional attributes” about the procedure — like whether it was diagnostic or therapeutic in intent. Paracentesis, a procedure used to remove fluid from the abdominal cavity, can be either therapeutic or diagnostic. Often providers don’t specify in their documentation whether they performed a therapeutic or diagnostic paracentesis, leaving the coder to figure it out. As it turns out, Nemchik and Yousfi explain, coding paracentesis as a therapeutic procedure causes no change in the DRG assignment. But code it as diagnostic and the DRG shifts to surgical, nearly doubling both the relative DRG weight — and the payment.

What About You?

Have you run into any issues with ICD-10-PCS and DRGs? Let us know in the comment box below!

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Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

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