Knowledge Base Article

The June 26th edition of the Wednesday@One included the article Palmetto Posts a Series of DRG Education Articles by Debbie Rubio. Debbie provided highlights of recently posted DRG specific articles that Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M has been posting on their CERT Topics webpage (JJ Part A CERT General Information or JM Part A CERT General Information).

Palmetto GBA has continued to post DRG specific articles. Today we highlight new DRG Articles that have been posted, including highlights from each of the articles.  

DRG 003: Mechanical Ventilation

• Provides clinical findings for when a mechanical ventilator should be considered (i.e., Respiratory rate > 30/min, inability to maintain arterial oxygen saturation > 90% with fractional inspired oxygen (Fio2) > 0.60).
• Lists the ICD-10-PCS procedure codes for consecutive number of hours receiving respiratory ventilation.
• Billing, compliance and reimbursement guidance when reporting mechanical ventilation (i.e., calculate the duration of time in hours, not days).

DRG 207: Respiratory System Diagnoses with Ventilator Support >96 Hours

• Provides an example of improper billing.
• Offers tips for accurate billing of DRG 207.
• Cites the Officer Inspector General (OIG) report Medicare Improperly Paid Hospitals for Beneficiaries Who Had Not Received 96 or More Consecutive Hours of Mechanical Ventilation.

DRGs 453, 454, 455: Combined Anterior/Posterior Spinal Fusion with MCC, with CC and without CC/MCC

• Provides a list of ICD-10-PCS procedure codes for Anterior Spinal Fusion and Posterior Spinal Fusion, noting “assignment to one of the combined spinal fusion MS-DRGs requires that a code from each list be reported.”
  

DRG 560: Aftercare, Musculoskeletal System and Connective Tissue with CC

• Palmetto notes this DRG does not include complications of an internal orthopedic device (DRG codes 495-499) or local excision and removal of internal fixation devices (DRG codes 494-499).
• Provides the top three ICD-10-CM Diagnosis Codes and ICD-10-PCS procedure codes used with this DRG.

DRG 627: Thyroid, Parathyroid and Thyroglossal Procedure without CC/MCC

• Provides anatomy and physiology discussion of the thyroid and parathyroid glands.
• Discusses a thyroglossal duct cyst procedure.
• Provides tips to meet medical necessity of admissions for procedures and surgeries including guidance that “when patients are admitted for the sole purpose of performing the procedure(s), the inpatient admission will be denied if documentation does not support the need for intense post-operative treatment warranting inpatient admission.”

DRG 627 represents an inpatient admission where no major comorbidity/complication (MCC) or comorbidity/complication (CC) was coded. Since Palmetto indicates the admission would be denied when the sole purpose of the admission was for the procedure, I was curious to see the data on patient volumes. The table below highlights the volume of claims, average charges, average actual payment and average length of stay by state in calendar year 2018.

As of July 8th, 2019 Palmetto GBA has posted nineteen DRG specific articles. Currently only Psychoses (DRG 885) and Renal Failure (DRG 682) have come under scrutiny in the Targeted Probe and Educate (TPE) Program. It will be interesting to follow and see what DRGs may become part of the TPE Program in the future.