Homogeneity of resource use
Clinically meaningful
Practical number of classes
Based on routinely available data
(Fetter et al, 1991)
General principleGeneral principle MajorMajorDiagnosticDiagnosticCategoryCategory
OR ProcedureOR Procedure
DRGDRG
PrincipalPrincipalDiagnosisDiagnosis Secondary Secondary
DiagnosesDiagnoses
Age, Age, Discharge type,…Discharge type,…
ICD-9-CMICD-9-CM
ICD-10ICD-10
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Severity refined(AR-DRG concept)
• Bilateral /Multiple procedures• Coding: ICD-10 2007+ICD-10-TM (Dx)
ICD-9-CM 2007 with Extension
Complete ICD-10/ ICD-9-CM library
HCFA DRG Commonly used
ICD code only
2012
1,283
511
511
1,920
2,450
1998
2003
2001
2007
Version Refined Diagnosis code
Procedure code Groups Implement
1 NoICD-10 (WHO)
1992ICD-9-CM
2000 511 Nov 1998
2 No ICD-10 (WHO) 1992
ICD-9-CM 2000 511 Feb 2001
3
3.0 5 levels ICD-10 (WHO) 1992
ICD-9-CM 2000 1,283 Oct 2003
3.1 5 levels ICD-10 (WHO) 1992
ICD-9-CM 2000 1,283 Apr 2005
3.3 5 levels ICD-10 (WHO) 2005
ICD-9-CM 2005 1,283 Feb 2006
3.5 5 levels ICD-10 (WHO) 2005
ICD-9-CM 2005 1,467 -
4 5 levelsICD-10 (WHO)
2007 + ICD-10-TM*
ICD-9-CM 2007
with extension1,920 Oct 2007
5 5 levelsICD-10 (WHO)
2010 + ICD-10-TM*
ICD-9-CM 2010
with extension2,450 Apr 2012
* For data entry only (not for new classification)
ICDICD--1010
Volume 2Instruction manual
Version for 2010
Volume 1Tabular list
Volume 3Alphabetical
index
ICDICD--1010--TMTM
Volume 1Tabular list
Volume 2Index
Thai modification
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Diseases
Injuries
Symptoms
Reasons for encounter
Factors that influence health status
External causes of disease
MortalityMorbidity
Main diagnosis that need medical care of this admission
Must be disease or condition that present before admission
PregnancyPregnancy, , childbirth & childbirth & perpeureumperpeureum
NeonatesNeonates
HIV HIV
CancerCancer3/14
Disease or condition other than PDxMay be Comorbidity or Complication but must be the problem that need medical care during the admission
“Comorbidity” or “Complication”(not “Other diagnosis”)ICD-10 WHO or ICD-10-TM ThaiDRG v4 allows only 12 codes
SDxSDx ((CCs) CCs)
Not used for DRG refinementNot used for DRG refinement
Not used for DRG groupingNot used for DRG groupingbutbut must be coded for must be coded for
reimbursement in reimbursement in ‘Accident’ cases (NHSO) ‘Accident’ cases (NHSO)
PDxPDx
DRG RW WTLOS OT OF Description04520 0.6156 4.63 14 0.57 Respiratory infection/inflammation, no CC
04521 0.7143 5.14 16 0.76 Respiratory infection/inflammation, w mild CC
04522 1.0663 6.47 21 0.63 Respiratory infection/inflammation, w mod CC
04523 1.6098 8.11 29 0.87 Respiratory infection/inflammation, w severe CC
04524 3.5153 11.84 46 1.00 Respiratory infection/inflammation, w catastrophic CC
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Non-OR procedure
Non-OR procedure affect DRG
OR procedure
•• RadiosurgeryRadiosurgery•• ExtractionExtraction & & restorationrestoration, , toothtooth•• ContinuousContinuous mechanicalmechanical ventilationventilation•• CardiacCardiac diagnosticdiagnostic procedureprocedure•• SkinSkin & & subcutaneoussubcutaneous tissuetissue procedureprocedure•• EndoscopeEndoscope•• PlasmapheresisPlasmapheresis•• TracheostomyTracheostomy
720 Low forceps operation721 Low forceps op w episiotomy7221 Mid forceps op w episiotomy7229 Other mid forceps operation7231 High forceps op w episiotomy7239 Other high forceps operation724 Forceps rotation of fetal head7251 Partial breech ext w forceps7252 Other partial breech extraction7253 Total breech ext w forceps7254 Other total breech ext w forceps7271 Vacuum extraction w episiotomy7279 Other vacuum extraction7321 Internal & combined version wo ext7322 Internal & combined version w ext733 Failed forceps7351 Manual rotation fetal head
7359 Other manual assist delivery738 Op on fetus to facilitate delivery7391 External version7392 Replaced prolapsed umbilical cord750 Intra-amniotic injection for abortion751 Diagnostic amniocentesis752 Intrauterine transfusion7531 Amnioscopy7533 Fetal blood sampling & biopsy7537 Amnioinfusion754 Manual removal of retained placenta7562 Repair current OB laceration rectum7569 Rep oth curr OB laceration757 Manual explore uterine cavity, PP7591 Evac OB incision hematoma perineum7592 Evac other hematoma vulva/vagina7594 Manual replacement of inverted uterus
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0102 Ventriculopunct thru cath0109 Other cranial puncture0331 Spinal tap247 Applic orthodont appliance3404 Insertion of ICD3491 Thoracentesis3891 Arterial catheterization3892 Umbilical vein cath3893 Venous catheterization3894 Venous cutdown5491 Paracentesis5711 Percutan bladder aspirat5751 Excision of urachus5794 Insert indwelling cath598 Ureteral catheterization8191 Arthrocentesis8321 Soft tissue biopsy8611 Skin & subq biopsy8659 Skin closure NEC
8703 C.A.T. scan of head8741 C.A.T. scan of thorax8801 C.A.T. scan of abdomen8871 Diag US of head & neck8872 Diag US of heart8875 Dx ultrasound-urinary8876 Dx ultrasound-abdomen8891 MRI of brain & brainstem9390 CPAP9391 IPPB9608 Insert intestinal tube9623 Dilation anal sphincter9635 Gastric gavage9671 Cont mech vent < 96 hrs
9901 Exchange transfusion9903 Whole blood transfus NEC9904 Packed cell transfusion9905 Platelet transfusion9906 Coag factor transfusion9907 Serum transfusion NEC9909 Transfusion NEC9914 Inject gamma globulin9915 Parent infus nutrit sub9960 Cardiopulm resuscitaton9962 Oth elec countershock hrt
Closed biopsyClosed biopsySpecial investigationSpecial investigation CT scan CT scan MRIMRI U/S,…U/S,…
Blood (& components) transfusionBlood (& components) transfusion9903 Whole blood transfusion NEC 9904 Packed cell transfusion 9905 Platelet transfusion
99.2-, 99.3- Therapeutic radiology 99.25 Inject. cancer chemotherapy
Z51.0 Radiotherapy sessionZ51.1 Chemo℞ session for neoplasm
99.03 Whole blood transfusion99.04 Packed cells transfusion99.05 Platelets transfusion
Closed biopsy, Special X-ray, US, CT, MRI, Nuclear scan,…
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9427 Other electroshock therapy (MDC 19)
9851 ESWL: kidney/ ureter /bladder (MDC 11)
9910 Thrombolytic injection / infusion (MDC 5)
9920 Platelet inhibitor injection/infusion (MDC 5)
* ESWL = Extracorporeal shock wave lithotripsy
99 9 9 9 99+
Example Phacoemulsification & aspiration of cataract both eyes in the same operation.
1
2 sides1st
operation
3 4
Phacoemulsificationand aspiration of
cataract
1 12+1 3 4 1 11+
1 3 4 1 21+
Example Phacoemulsification & aspiration of cataract both eyes in 2 operations.
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DC Desc0112 Craniotomy (multiple) for trauma0113 Craniotomy (multiple),0211 Multiple major lens procedures0212 Multiple other lens procedures0536 Multiple wound debridement (in CVS)0801 Bilateral or multiple major joint proc of lower ext0828 Multiple (2-4) wound debridement w skin graft except
hand for MS&CT0830 Multiple (2-4) wound debridement for MS&CT0836 Multiple (>4) wound debridement for MS&CT0910 Skin graft and multiple debridement for ulcer or cellulitis2417 Multiple wound debridement for MST
RW
DRG
Non OR Procedure
ORProcedure
Secondary diagnosis 1
Principal diagnosis
Secondary diagnosis 2
0.2727
01670Other Head injury, no CC
--
--
Head injury(S099)
Summary 1
1.0973
01650Intracranial injury, no CC
--
--
Acute subdural
hematoma (S065)
Summary 2
3.9029
01010Craniotomy for trauma, no CC
--
Removal of subdural
hematoma (0131)
Acute subdural
hematoma (S065)
Summary 3
6.2971
01013Craniotomy for trauma, with severe CC
--
Removal of subdural
hematoma (0131)
Pneumonia (J189)
Acute subdural
hematoma (S065)
Summary 4
01163Trach for NS disease, w mild to sev CC
Tracheostomy(311)
22.5935
Removal of subdural
hematoma (0131+21)
Acute subdural
hematoma (S065)
Summary 6
Pneumonia (J189)
10.8629
01129Craniotomy (multiple) for trauma, with or wo CC
Removal of subdural
hematoma (0131+21)
Pneumonia (J189)
Acute subdural
hematoma (S065)
Summary 5
--
ICD as classification
Coding rules
Coding quality
Upcoding
8/14
ICDICD--1010
Volume 1Tabular list
Volume 2Instruction manual
Volume 3Alphabetical
index
“The condition, diagnosed at the end of the episode of health care, primarily responsible for the patient’s need for treatment or investigation.If there is more than one such condition, the one held most responsible for the greatest use of resources should be selected.”
Reason for admission Resource
Diagnosis that either co-exists with the main diagnosis at the time of admission, or which appears during the episode of care.
Other conditionOther condition
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Dagger Dagger † / Asterisk / Asterisk *Dual Codes (Dual Codes (1 1 DxDx 2 2 codes)codes)
• 2 dimensions of disease– Cause (Etiology) – Effect (Manifestation)
• Code Dagger first Asterisk
Tuberculous meningitis
Tuberculousmeningitis
Meningitis in bacterial diseases
classified elsewhere
A17.0† G01*
Bureau Policy and Strategic, MoPH
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If the patient had been previously diagnosed with heart disease such as Mitral stenosis, Tetralogy of Fallot with congestive heart failure, etc. The principal diagnosis should be Congestive heart failure, followed by heart disease as comorbidity.However, if a patient with congestive heart failure and was diagnosed heart disease for the first time. Select heart disease to be principal diagnosis and congestive heart failureas a comorbidity.
Physician should diagnoses Congestive heart failure, in specific term as left ventricular failure, right ventricular failure secondary to left ventricular failure, biventricular failure or right ventricular failure.
Patients with symptom of severe dyspnea. Chest radiography showed infiltration in both lungs and was diagnosed as acute pulmonary edema.
If heart disease was the cause, The diagnosis was acute cardiogenic pulmonary edema or acute left ventricular failureif it caused by other heart disease, e.g. drug, patient should be diagnosed as acute non-cardiogenic pulmonary edema.
If diagnosed as Right ventricular failure secondary to left ventricular failure, Biventricular failure or Right ventricular failure, code I50.0 Congestive heart failure.
If diagnosed as Left ventricular failure or Acute cardiogenic pulmonary edema, code I50.1 Left ventricular failure.
If diagnosed only Heart failure. code I50.9Heart failure, unspecified.
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MisMis--specificationspecification Invalid Diagnosis summaryInvalid Diagnosis summary
MisMis--coding coding UpcodingUpcoding
ResequencingResequencing Incorrect Incorrect PDxPDx//SDxSDx
sequencing by codersequencing by coder
OtherOther e.g. Age data e.g. Age data
Simborg, D.W., "DRG Creep: A New Hospital-Acquired Disease," N Engl J Med, June 25, 1981, 304(26), pp. 1602-1604.
AuditAudit
• Control mechanism• Scheme oriented
– UC Coding audit, Clinical audit– CSMBS Billing, Quality of care
+Coding audit-- SS Coding audit (begin 2013)
• System audit + Medical record audit
Inpatientcare
In-patientSummary
Coding(ICD-10,
ICD-9-CM)
StandardData set
DRG’sDRG’sDRG’sDRG’s
DRG GROUPER
11
22
Coding auditCoding audit
12/14
Quality auditQuality audit• OPD card• Discharge summary• History, Physical examination• Progress note• Doctor’s order• Operative note in surgical case• Anesthesia record• Vital ’s sign record• Nurse admission note• Nurse’s note (progress and others)• Medication record
Database
Acute Duodenal ulcer w hemorrhage
HypernatremiaPseudomonas pneumonia-Acute Posthemorrhagic anemia
Liver cirrhosis
Coding auditCoding audit
0 No disagreement1 Principal diagnosis ( PDx )
1a Missing PDx1b Invalid PDx1c Non-specific PDx
2 Additional diagnosis (Comorbidity & Complication: CC )
2a Missing CC2b Invalid CC2c Non-specific CC2d Unjustified CC
3 Operative (Op)3a Missing Operation3b Invalid Operation3c Non-specific Operation 3d Unjustified Operation
5 Not –summarized6 Other problems
0 No disagreement1 Principal diagnosis (PDx)
1a Missing PDx code1b Invalid PDx code1c Non-specific PDx code
2 Additional diagnosis (Comorbidity & Complication: CC ) 2a Missing CC code2b Invalid CC code2c Non-specific CC code2d Unjustified CC code
3 Incorrect Operation code3a Missing Operation code3b Invalid Operation code3c Non-specific Operation code3d Unjustified Operation code
6 Other problems
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2006 2007 2008 2009 2010 2011
Method Random Random Random Selected Selected & Random Selected
N % N % N % N % N % N %
Target 1,434100
59,897100
65,289100
34,830100.7
43,621100.7
54,687103.2
59,897Result 1,434 65,289 35,073 43,901 56,410
Errors (Charts)
620 43.2 39,414 65.8 40,227 61.6 30,582 87.2 39,693 90.4 51,622 94.4
Summaryerror 43.3 55.1 52.4 82.8 80.8 81.9
Coding error 58.4 63.1 60 89.5 88.5 90.3
Others - - 4.1 6.3 8.1 10.6
AdjRW change 106 1,001 261 -13,037 -18,583 -19,805
*N = Number of charts
2006 2007 2008 2009 2010 2011
Method Random Random Random Selected Selected & Random Selected
N % N % N % N % N % N %
Target 1,434100
59,897100
65,289100
34,830100.7
43,621100.7
54,687103.2
59,897Result 1,434 65,289 35,073 43,901 56,410
Errors (Charts)
620 43.2 39,414 65.8 40,227 61.6 30,582 87.2 39,693 90.4 51,622 94.4
Summary error 43.3 55.1 52.4 82.8 80.8 81.9
Coding error 58.4 63.1 60 89.5 88.5 90.3
Others - - 4.1 6.3 8.1 10.6
2006 2007 2008 2009 2010 2011
Method Random Random Random Selected Selected & Random Selected
N % N % N % N % N % N %
Target 1,434100
59,897100
65,289100
34,830100.7
43,621100.7
54,687103.2
59,897Result 1,434 65,289 35,073 43,901 56,410
2006 2007 2008 2009 2010 2011
Method Random Random Random Selected Selected & Random Selected
Bureau of Claim and Medical Audit :NHSO
20112011Selected Random
N % N %
Target 54,687103.2
3,045100
Result 56,410 3,045
Error (Charts) 51,622 94.4 1,999 65.7
• Summary errors 81.9 58.7
• Coding errors 90.3 64.4
• Other 10.6 4.7
Bureau of Claim and Medical Audit :NHSO
• Severe CC level but low LOS & expense (Charge)
• High RW but low LOS & expense
• DRG with Continuous mechanical ventilation/ Craniotomy but low expense
• OR Procedure unrelated to Principal Diagnosis
• ……Bureau of Claim and Medical Audit :NHSO
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