Most Responsible Diagnosis & Complexity Coding HS 317 b - Coding & Classification of Health Information
MCC CMG 4 Complexity levels RIW
Complexity Levels PLX 1 - no complexity n PLX 2 - complexity related to chronic conditions n PLX 3 - complexity related to serious or important conditions n PLX 4 - highest complexity - complexity related to life-threatening conditions n PLX 9 - complexity & age split are inherent in the CMG so no need for further PLX n
Complexity 9 n Assigned to ¨ MCC 14 Pregnancy & Childbirth ¨ MCC 15 Newborns & Neonates ¨ MCC 19 Mental Diseases & Disorders ¨ MCC 24 HIV Infections ¨ MCC 25 (CMG 651 -659, 674 -679 only) Significant Trauma ¨ MCC 99 Ungroupable Data
Complexity Assignment n Identifies other diagnoses (other than most responsible diagnosis) which may prolong the length of stay and/or the need for more costly treatment.
Resource Intensity Weight Resource – total hospital service cost including fixed and variable components n Intensity – the amount of service utilized n Weight – relative value of each case compared to the “average case” which is the value of “ 1” n
Resource Intensity Weight (RIW) A statistical cost which recognizes that not every patient consumes the same resources during their stay in hospital. n Resources can differ due to: n ¨ Differences in LOS ¨ Types of resources used (medical/surgical) ¨ Nursing intensity, etc.
Categories of patients n n Typical – patient who receives a fully successful course of treatment in a single institution and is discharge when they no longer require the services of an acute care hospital Atypical – patient who exhibits a different pattern of care either because they do not complete a successful course of treatment in a single hospital visit or because the LOS is greater than the statistical trim point for CMG/Plx Level (examples: sign-outs, death, transfers, long stay outliers)
Comorbidity conditions n Identify other diagnosis to indicate 5 complexity levels - only 465 codes that impact complexity level n Significantly impacts complexity levels and RIWs
Comorbidities n All conditions that coexist at the time of admission or develop subsequently & demonstrate ¨ Significantly affects the treatment received ¨ Requires treatment beyond maintenance of the pre-existing condition ¨ Increases the LOS by at least 24 hours
How to determine significance? n Documented evidence in physician’s notes/discharge summary that: ¨ Clinical evaluation/consultation document a new or amended course of treatment ¨ Therapeutic treatment/intervention with a code assignment of ’ 50’ or greater from Section 1 of CCI ¨ Diagnostic intervention, inspection or biopsy with a code assignment from Section 2 of CCI n Extended the LOS by at least 24 hours
Post procedural condition Documented by physician as a complication of the procedure n Present at discharge n Persist post-procedurally for at least 96 hours n
Valuable tools for coding Nurses notes n Pathology reports n Laboratory reports n Autopsy reports n Medication profiles n Radiological investigations n Nuclear imaging n etc n
Comorbid Conditions Identification n A one digit number or letter to identify the relationship of the diagnosis to the patients stay in hospital ¨ Diagnosis type 1, 2, 3, 4, 6, 9, 0, W, X, Y
Diagnosis type 1 n Pre-Admit Comorbidity ¨A condition that existed pre-admission ¨ Satisfies the requirements for determining comorbidity
Diagnosis type 2 n Post-admit Comorbidity ¨A condition that arises post-admission ¨ Satisfies the requirements for determining comorbidity
Diagnosis Type 3 n Secondary Diagnosis ¨A condition or diagnosis which may or may not have received treatment ¨ Does not satisfy the requirements for determining comorbidity ¨ Some codes require a diagnosis type 3
n Diagnosis type 3 conditions are coded if they are listed on the: ¨ Front sheet ¨ Discharge summary ¨ Death certificate ¨ History & physical ¨ Pre-operative anesthetic consult
Diagnosis Type 6 n Proxy MRDx ¨ It is assigned to an asterisk code, the manifestation in a dagger/asterisk convention when it fulfills the requirements stated in the definition of MRDx. ¨ Can only apply diagnosis type 6 to the second line of a diagnosis field of the abstract. n Only one asterisk code is allowed a diagnosis type 6 per encounter.
Diagnosis type W, X, or Y n Service Transfer Diagnosis ¨A diagnosis associated with the first/second/third service transfer ¨ Recording the days spent under another patient service
Diagnosis Type 4 Morphology Codes n Morphology codes derived form ICD-O codes describing the type and behaviour of neoplasm
Diagnosis type 9 – External Cause of Injury code Mandatory to use with codes in the range of S 00 -T 98, injury, poisoning and certain other consequences of external causes n Category U 98. ~, Place of Occurrence n ¨ Mandatory with codes in the range of W 00 - Y 34 ¨ Exception Y 06 & Y 07
Diagnosis Type 0 Use to distinguish babies born via caesarean section from those born vaginally n Application code range is Z 38. ~ Liveborn infants according to place of birth & P 03. 4~ Fetus and newborn affected by caesarean delivery n
Goals for Coding To distinguish between the diagnosis type categories used in DAD coding/abstracting & correctly apply them n To interpret & apply the Canadian Coding Standards for ICD-10 -CA & CCI n To recognize the importance of consistent application of standards to data quality n
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