Health Information Management

Q&A: MS-DRG assignment and cystic fibrosis

CDI Strategies, August 30, 2012

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Q: I was interested in further discussion about cystic fibrosis coding. I am conducting an audit on MS-DRGs 177, 178, and 179, Respiration infections and inflammation with MCC, CC, and without CC/MCC. Cystic fibrosis with pulmonary manifestation charts can be tricky. I believe the correct and appropriate DRGs for these cases falls to 177–179. They certainly command the respect of a higher-weighted DRG. However, AHA Coding Clinic for ICD-9-CM advice can be ambiguous.

A: Coding Clinic has been very clear in the sequenc­ing of circumstances whereby a patient with known cystic fibrosis is admitted primarily to treat a pulmonary manifestation in light of the instructions in the coding manual’s ICD-9-CM Index and in the Table of Diseases.
Look at the ICD-9-CM Table of Diseases. The only sequencing instruction for 277.02, Cystic fibro­sis with pulmonary manifestation is to use an additional code to identify any infectious organism present, such as pseudomonas (041.7). There is no requirement to code 277.02 first if a patient is admitted with a pulmonary manifestation linked to cystic fibrosis.
Also look at Coding Clinic, Fourth Quarter 1990, p. 17, which states:
In accordance with UHDDS requirements, the condition that occasions the admission to the hospital should be coded as the principal diagnosis. If a patient with cystic fibrosis is admitted due to a complication such as pneumothorax, 512.8; acute bronchitis, 466.0; acute cor pulmonale, 415.0; rectal prolapse, 569.1; gastroesophageal reflux, 530.1; the complication should be coded as the principal diagnosis and cystic fibrosis, 277.0x, reported as an additional diagnosis. If, however, the physician determines that the admission is due to the cystic fibrosis rather than a complication, cystic fibrosis should be assigned as principal diagnosis.
Patients with cystic fibrosis have a higher likelihood of pseudomonas as the causal agent. If their cultures are negative but the patient receives reasonable antipseudomonal therapy (e.g., IV pipercillin or oral ciprofloxacin) for a reasonable duration (e.g., over three or four days), and if the provider documented “pneumonia probably due to pseudomonas” at the time of discharge, then the coder can code pseudomonas pneumonia as the principal diagnosis, resulting in MS-DRG 177, Respiratory infections and inflammation with MCC (277.02 would be the MCC).
While this does not change the base DRG in APR-DRGs (pertinent to N.Y. Medicaid), it does increase the SOI and ROM that does impact reimbursement and mortality ranking.
Editor’s Note: James S. Kennedy, MD, CCS, CDIP, manag­ing director of clinical documentation and coding integrity at FTI Consulting in Brentwood, Tenn., answered this question in the July edition of the CDI Journal.This topic was also addressed during the May 2012 ACDIS Quarterly Conference Call. To become an ACDIS member call our Member Relations Department at 877-240-6586.

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