1 / 24

Most Responsible Diagnosis & Complexity Coding

Most Responsible Diagnosis & Complexity Coding. HS317b - Coding & Classification of Health Information. MCC. 4 Complexity levels. CMG. RIW. Complexity Levels. PLX 1 - no complexity PLX 2 - complexity related to chronic conditions

elgin
Download Presentation

Most Responsible Diagnosis & Complexity Coding

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Most Responsible Diagnosis & Complexity Coding HS317b - Coding & Classification of Health Information

  2. MCC 4 Complexity levels CMG RIW

  3. Complexity Levels • PLX 1 - no complexity • PLX 2 - complexity related to chronic conditions • PLX 3 - complexity related to serious or important conditions • PLX 4 - highest complexity - complexity related to life-threatening conditions • PLX 9 - complexity & age split are inherent in the CMG so no need for further PLX

  4. Complexity 9 • 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

  5. Complexity Assignment • Identifies other diagnoses (other than most responsible diagnosis) which may prolong the length of stay and/or the need for more costly treatment.

  6. Resource Intensity Weight • Resource – total hospital service cost including fixed and variable components • Intensity – the amount of service utilized • Weight – relative value of each case compared to the “average case” which is the value of “1”

  7. Resource Intensity Weight (RIW) • A statistical cost which recognizes that not every patient consumes the same resources during their stay in hospital. • Resources can differ due to: • Differences in LOS • Types of resources used (medical/surgical) • Nursing intensity, etc.

  8. Categories of patients • 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)

  9. Comorbidity conditions • Identify other diagnosis to indicate 5 complexity levels - only 465 codes that impact complexity level • Significantly impacts complexity levels and RIWs

  10. Comorbidities • 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

  11. How to determine significance? • 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 • Extended the LOS by at least 24 hours

  12. Post procedural condition • Documented by physician as a complication of the procedure • Present at discharge • Persist post-procedurally for at least 96 hours

  13. Valuable tools for coding • Nurses notes • Pathology reports • Laboratory reports • Autopsy reports • Medication profiles • Radiological investigations • Nuclear imaging • etc

  14. Comorbid Conditions Identification • 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

  15. Diagnosis type 1 • Pre-Admit Comorbidity • A condition that existed pre-admission • Satisfies the requirements for determining comorbidity

  16. Diagnosis type 2 • Post-admit Comorbidity • A condition that arises post-admission • Satisfies the requirements for determining comorbidity

  17. Diagnosis Type 3 • 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

  18. Diagnosis type 3 conditions are coded if they are listed on the: • Front sheet • Discharge summary • Death certificate • History & physical • Pre-operative anesthetic consult

  19. Diagnosis Type 6 • 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. • Only one asterisk code is allowed a diagnosis type 6 per encounter.

  20. Diagnosis type W, X, or Y • Service Transfer Diagnosis • A diagnosis associated with the first/second/third service transfer • Recording the days spent under another patient service

  21. Diagnosis Type 4 Morphology Codes • Morphology codes derived form ICD-O codes describing the type and behaviour of neoplasm

  22. Diagnosis type 9 – External Cause of Injury code • Mandatory to use with codes in the range of S00-T98, injury, poisoning and certain other consequences of external causes • Category U98.~, Place of Occurrence • Mandatory with codes in the range of W00-Y34 • Exception Y06 & Y07

  23. Diagnosis Type 0 • Use to distinguish babies born via caesarean section from those born vaginally • Application code range is Z38.~ Liveborn infants according to place of birth & P03.4~ Fetus and newborn affected by caesarean delivery

  24. Goals for Coding • To distinguish between the diagnosis type categories used in DAD coding/abstracting & correctly apply them • To interpret & apply the Canadian Coding Standards for ICD-10-CA & CCI • To recognize the importance of consistent application of standards to data quality

More Related