MS DRG of the Week: MSDRG 190: COPD with MCC

Change the Principal diagnosis

·         Likely alternate principal diagnoses  include ...

o   348.1 Anoxic brain damage                                                            →  DRG 91                         

o   415.1 Pulmonary embolus                                                              →  DRG 176

o   507.0 Aspiration pneumonitis or bronchitis                                →  DRG 177        CW 2.07

o   162.30  Pancoast tumor                                                                  →  DRG 180

o   518.81 Acute respiratory failure                                                    →  DRG 189        CW 1.28

o   486 Pneumonia                                                                                 →  DRG 193        CW 1.48

o   515 Interstitial lung disease / interstitial pneumonitis              →  DRG 196        CW 1.61

o   428.21 Acute systolic heart failure                                                →  DRG 291        CW 1.49

o   578.9 GI bleed                                                                                   →  DRG 377

o   197.7 Metastases to liver                                                                →  DRG 435

o   584.9 Acute kidney failure                                                              →  DRG 682        CW 1.64

o   996.64 UTI complicating indwelling urinary catheter                →  DRG 698

o   288.0 Neutropenia (due to infection)                                           →  DRG 808

o   038.9 Septicemia                                                                              →  DRG 871

·       Patients with COPD exacerbation (Case weight 1.19) often have other concurrent conditions which may be co-equal in meeting the definition of principal diagnosis (ICD-9-CM Official Guidelines for Coding and Reporting, Section II). Relative case weights of selected common alternative principal diagnoses are noted above.

·       Aspiration pneumonia and aspiration bronchitis share the same code (507.0). Consider a query if medical records indicate presence of both aspiration and bronchitis, even if no pneumonia.

·       Principal diagnoses which lead to DRG 196 include Post-inflammatory pulmonary fibrosis (515) and Alveolar/parietoalveolar pneumonopathy (516.8). Look for complications of amiodarone or methotrexate therapy. Consider re-reading Coding Clinic 2Q 2006 page 20 for discussion of this.

·       If you are considering respiratory failure, make sure that medical record documentation supports both the diagnosis and the acuity that you recommend.  Don't accept a physician diagnosis of respiratory failure without verifying supporting documentation.  RAC reviewers are likely to check carefully for clinical indicators that support the presence of respiratory failure.

MCC Conditions

·       DRG 190 already has an associated MCC condition.  Any changes associated with a COPD principal diagnosis will be down-codes.

o   Delete pneumonia (486)

§  Patients with COPD are often admitted with a suspicion of pneumonia on admission.  Sometimes pneumonia is ruled out during the admission.

o   Delete myocardial infarction

§  The cardiologist assessment may be that the small troponin bump was due to COPD exacerbation.