Question

Medicare Severity DRGs – Part I

Medicare Severity Diagnosis-Related Groups (MS-DRGs) are payment groups designed for the inpatient hospital Medicare population under the IPPS. Patients with similar clinical characteristics and similar costs are assigned to a MS-DRG. The MS-DRG is linked to a fixed payment amount based on the average cost of patients in the group. The MS-DRG is calculated by using the principal diagnosis, surgical procedure, age of patient, gender, and disposition of the patient (discharge status – where did the patient go upon discharge? Example: home, home health, skilled nursing facility, rehabilitation, expired, etc.) Some MS-DRGs are medical (no surgery) and others are surgical (with a surgical procedure). Some MS-DRGs have complications or cormorbidities (CCs) or major complications or comorbidities (MCCs). A complication is a new problem resulting from illness, procedure performed, or treatment provided. Cormorbidities are coexisting conditions (diabetes mellitus, hypertension, UTI) for which the patient receives treatment during the same inpatient visit.

A weight is assigned to each MS-DRG and reflects the average relative costliness of cases in that group compared with the costliness for the average Medicare case. The weight times the base rate dollar amount Medicare assigns to each facility for reimbursement are multiplied to see the payment for the case. Example: if a MS-DRG is worth a weight of 1.5 and the Medicare hospital base rate is $5000, multiply 1.5 x $5000 = $7500 for that case.

Assignment 1:

Review the case studies to answer the questions for each table. The MS-DRG tables are created for these assignments.

1. Joe Smith is a 65-year-old male who was admitted for congestive heart failure (CHF). He is discharged after developing pneumonia during the hospital stay. He was hospitalized for 7 days (LOS 7 days). The disposition for this discharge status is home. He needs to follow-up with his Internal Medicine physician in three days. The coder assigned I150.9, E10.9, J18.9 and I10 and the pneumonia shows as an MCC.

MS-DRG	MDC	TYPE	MS-DRG Title	WEIGHT	LOS	RATE
291	05	MED	Heart Failure & Shock w MCC	1.5214	4.7	$2,522.53
292	05	MED	Heart Failure & Shock w CC	0.9784	3.8	$1,501.47
293	05	MED	Heart Failure & Shock w/o CC/MCC	0.6512	2.5	$1,121.32

1. Which MS-DRG weight would apply to this patient’s case? _______________________________
2. What is the major complication or comorbidity (MCC) diagnosis code? ____________________

2. Marsha Brady is a 63-year-old female admitted after falling at home. After study, she is diagnosed with left upper femur fracture and she requires surgery of ORIF (open reduction, internal fixation). After surgery, she suffered a cardiac arrest which was converted. She was found to have cardiomyopathy. Her discharge disposition is skilled nursing facility (SNF). The coder assigns the following codes based on physician documentation: S72.009A, I97.121, I42.9, and OQS704Z with the cardiac arrest showing as a CC.

MS-DRG	MDC	TYPE	MS-DRG Title	WEIGHT	LOS	RATE
480	08	SURG	Hip & Femur Procedures Except Major Joint c MCC	3.1526	7.0	$4,114.25
481	08	SURG	Hip & Femur Procedures Except Major Joint w CC	1.8921	4.7	$2,898.35
482	08	SURG	Hip & Femur Procedures Except Major Joint w/o CC/MCC	1.6455	3.7	$2,344.57

1. What is the MS-DRG? __________________________
2. What is the MS-DRG reimbursement rate? _______________________

Answer 1

1. Joe Smith is a 65-year-old male who was admitted for congestive heart failure (CHF). He is discharged after developing pneumonia during the hospital stay. He was hospitalized for 7 days (LOS 7 days). The disposition for this discharge status is home. He needs to follow-up with his Internal Medicine physician in three days. The coder assigned I150.9, E10.9, J18.9 and I10 and the pneumonia shows as an MCC.

a. In the present scenario of Mr.Joe Smith, The MS-DRG code assigned to him is 291 - Heart Failure & Shock w MCC

b. The major complication or comorbidity (MCC) diagnosis code is J189 - Pneumonia, unspecified organism

2. Marsha Brady is a 63-year-old female admitted after falling at home. After the study, she is diagnosed with a left upper femur fracture and she requires surgery of ORIF (open reduction, internal fixation). After surgery, she suffered a cardiac arrest which was converted. She was found to have cardiomyopathy. Her discharge disposition is a skilled nursing facility (SNF). The coder assigns the following codes based on physician documentation: S72.009A, I97.121, I42.9, and OQS704Z with the cardiac arrest showing as a CC.

The MS-DRG assigned to this case is - 481

The reimbursement rate for this case is - $2,898.35