MS-DRG Assignment

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1. Remember the 1. principal and secondary diagnosis and procedure codes

factors influenc- 2. sex
ing MS-DRG as- 3. age
signment: 4. discharge status
5. presence or absence of major complications and comor-
bidities (MCCs)
6. presence or absence of complications and comorbidities
(CCs)

2. groupers today, most MS-DRGs are calculated using software tools

known as groupers. Early on, they were determined using
a flow-chart book. The book contains a series of decision
tree diagrams. The same information would have been
necessary to determine the correct DRG (as MS-DRGs
were not implemented).

3. Principal and Does the logic look for a principal procedure code first?
Secondary Diag-
nosis and Proce- -If no, then a principal diagnosis code is reviewed for appro-
dure Codes priate placement in an MDC (major diagnostic category).
-If yes, then logic follows the surgical MS-DRGs pathways
for the admission.
-Next question: "Does the procedure code fall into the pre
MDC MS-DRG?" If yes, a MS-DRG is assigned.
--Currently, there are 17 pre-MDC groups.
--Examples include:
a) MS-DRG 01 (MDC PRE) HEART TRANSPLANT OR
IMPLANT OF HEART ASSIST SYSTEM W MCC
b) MS-DRG 014 (MDC PRE) ALLOGENIC BONE MAR-
ROW TRANSPLANT
-If no, pre MDC the remaining grouper logic is followed.

Secondary diagnosis codes are reviewed after the princi-

pal diagnosis for the selection of the correct MS-DRG.

The medical coder identifies all the principal and sec-

ondary diagnosis and procedure codes. This will lead to
the assignment of the correct DRG.

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4. Sex of the Patient There are specific codes and MS-DRGs that are gender
specific. Certain diagnoses and procedures can only be
assigned to males or females.

Examples of these include the following:

-Male Diagnoses
a) prostate cancer
b) hydrocele
c) torsion of testicle

-Male Procedures
a) orchiectomy
b) prostatectomy
c) vasectomy

-Female Diagnoses
a) endometriosis of ovary
b) dysmenorrhea
c) tubal pregnancy

-Female Procedures
a) salpingo-oophorectomy
b) hysterectomy
c) dilation and curettage (D&C)

5. Age of Patient If a patient in one age group tends to use more resources
than patients in another age group, then the MS-DRGs are
split according to age.

6. DRG When a patient is transferred from one acute care hospital

Assignment—Dis- to another or from one acute care hospital to a certain
charge Status postacute care provider (e.g., skilled nursing facility), the
payment for some MS-DRGs is reduced.

The MS-DRGs affected by being transferred to specific

post-acute care facilities is known as Post-Acute DRG.
Medicare identifies those MS-DRGs with an indicator of

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 MS-DRG Assignment
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"Yes." An example would be MS-DRG 031 Ventricular
Shunt Procedure w MCC.

7. DRG The presence of a major complication or comorbidity di-

Assign- agnosis can cause the patient's case to be grouped into
ment—Presence the higher-weighted MS-DRG. After determining if a MCC
or Absence of is present or not, the logic reviews for complications and
Major comorbidities (CCs).
Complications
and
Comorbidities
(MCCs) and
Complications
and
Comorbidities
(CCs)

8. MS-DRG Exam- -193 (MDC 04) SIMPLE PNEUMONIA & PLEURISY W

ples MCC
-194 (MDC 04) SIMPLE PNEUMONIA & PLEURISY W CC
-195 (MDC 04) SIMPLE PNEUMONIA & PLEURISY W/O
CC/MCC

9. Hospital Ac- It should be noted that hospital acquired conditions (HAC)

quired Condi- also factor into the assignment of MS-DRGs. Basically,
tions (HAC) these are codes that identify conditions that are high cost,
high volume, or both; they may also be CCs or MCCs. Most
importantly, they could have been reasonably prevented
through the application of evidence-based guidelines. The
point of this notification is that if the condition IS NOT
PRESENT ON ADMISSION, it will NOT be grouped to that
higher-paying MS-DRG. Review any code assignments
that are designated as HAC. Accurate and complete docu-
mentation is essential. Most facilities have a physician-led
review committee to investigate and develop additional
preventative measures.

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