Knowledge Base Article

Background

MMP first wrote about Palmetto GBA publishing articles about various DRGs in June of 2019. The first article released was about DRG 460: Spinal Fusion. Since then, DRG 460 has been added to the Jurisdiction J list of Active Medical Reviews under the Targeted Probe and Educate (TPE) Program.

​DRG specific articles can be found under General Information on the CERT Topics webpage on either JJ Part A CERT General Information or JM Part A CERT General Information. Information found in past and the most recent articles ranges from information about documentation requirements to information on assignment of principal and secondary diagnoses to coverage requirements to consideration of an alternate DRG.

On February 23, 2020, Palmetto GBA published an article about DRG 552 (Medical Back Problems with MCC) and DRGs 981, 982, and 983 (Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC respectively).

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‍DRG 552: Medical Back Problems without MCC

In this article, Palmetto GBA focuses on two common denial reasons associated with DRG 552 as well as claims processing tips and suggestions to prevent denials.

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Common Denial Reasons

• Requested Records Not Submitted: Reminder, when an Additional Documentation Request (ADR) is generated, the provider has 45 days to respond with medical records.
• Need for Service/item Not Medically and Reasonably Necessary

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Tips to Prevent Not Medically and Reasonably Necessary Denials

All tips reiterate the need to include documentation. Following are two tips from the article:

• Documentation supporting the need for inpatient care,
• Documentation provided to Palmetto GBA should include all clinical information available for the dates of services being billed.

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DRGs 981, 982, 983: Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC

Annually, CMS reviews procedures assigned to MS-DRGs 981 through 982 based on volume by procedure to see if it would be more appropriate to move procedures codes into one of the surgical MS-DRGs for the Major Diagnostic Category (MDC) into which the principal diagnosis falls. This article serves as a reminder of changes in the FY 2020 IPPS Final Rule. Following is a table of the ICD-10-PCS codes that would no longer group to DRGs 981, 982 and 983:

‍Potential Financial Impact

I was curious to see what the potential impact would be from these changes and turned to our sister company, RealTime Medicare Data (RTMD) to crunch the numbers. The following findings are based off paid Medicare fee-for-service claims in FY 2019 in Alabama.

All DRG 981, 982 and 983 Claims

• Volume: 1,126 claims
• Average LOS: 10.556
• National Average Payment Total: $22,488,788.40

DRGs with a Procedure No Longer Grouping to DRGs 981, 982, and 983

• Volume: 105 claims
• Average LOS: 10.99 days
• National Average Payment Total when Grouped to DRGs 981, 982, and 983: $2,276,263.87
• National Average Payment Total when Grouped into MDC based on Principal Diagnosis: $1,993,041.13
• Average Decrease per claim: -$2,697.36.

Top ICD-10-PCS Procedures Performed Now Grouping within an MDC

• 31 of 105 Claims: 0WPG03Z - Removal of Infusion Device from Peritoneal Cavity, Open Approach
• 24 of 105 Claims: 0QB10ZZ - Excision of Sacrum, Open Approach
• 16 of 105 Claims: 0WHG03Z - Insertion of Infusion Device into Peritoneal Cavity, Percutaneous Endoscopic Approach

In general, payment was lower when a procedure sequenced to an MDC. However, there were a few instances where the payment was higher. Either way, this is one more way that hospital reimbursement changed in FY 2020.