Most Responsible Diagnosis & Complexity Coding HS317B – Coding & Classification of Health Data 30/11/2018

Background on Standards 30/11/2018 Background on Standards In 1995 at a First Ministers meeting, the federal, provincial & territorial governments agreed that Canada would adopt a unified system for the collection of health care data. Discharge Abstract Database (DAD National Ambulatory Care Reporting System (NACRS) In 2001 ICD-10 was introduced to Canada in a staggered approach. Canadian Coding Standards for ICD-10-CA enhance the World Health Organization’s rules & guidelines. 30/11/2018

The idea: to create a database of health information that is relevant 30/11/2018 The idea: to create a database of health information that is relevant 30/11/2018

Health Information Database 30/11/2018 Health Information Database At a local level to demonstrate: quality improvement, program planning, benchmarking, research, strategic planning, utilization management, risk management, case costing & funding Provincially: case costing, funding, rationalization of services, population health, system evaluation & planning Nationally: evaluation of outcomes, grouping of data, healthcare planning, manpower planning, monitoring trends, morbidity and mortality reporting, patient safety 30/11/2018

Most Responsible Diagnosis Diagnosis Typing Interventions 30/11/2018 Most Responsible Diagnosis Diagnosis Typing Interventions Data Elements (demographics, etc) 30/11/2018

Process for Classification 30/11/2018 Process for Classification Identify Most Responsible Diagnosis Based on MRDx coded cases are slotted into one of 25 major clinical categories (MCC). Cases are grouped to similar conditions together into Case Mix Groups 30/11/2018

Medical/Surgical CMG Methodology 30/11/2018 Medical/Surgical CMG Methodology No Valid MRDx? CMG 999 Yes Yes Age < 29 MCC 15 Days No The grouper uses only selected information from the patient’s abstract, including age, gender, birth weight, medical diagnoses, interventions and whether the patient was a typical or an atypical visit (to be discussed later). Medical diagnoses and procedures are determined from the ICD-9/CCP, the ICD9-CM, or the ICD-10-CA/CCI classification systems. From the patient’s abstract, the Most Responsible Diagnosis (MRDx) 'the one diagnosis that describes the most significant condition of a patient that causes his/her stay in hospital' is used to assign the patient to one of the 25 MCC. This may not always be the condition for which the patient was initially admitted. Within each MCC, the presence or absence of an operative procedure will direct the patient towards a surgical or medical partition. In the surgical partition, the grouper loops through all procedures recorded on the patient’s abstract to find one that is in the same MCC as the MRDx. If more than one procedure is found that belongs in this MCC the case is assigned to the CMG highest on the hierarchy. The surgical hierarchy is a decision rule that orders procedures from most to least resource intensive. The hierarchy is defined by clinical judgement and expected resource consumption. If the only procedures that are recorded are not listed within the MCC of the MRDx, the case will be assigned to a CMG that is associated with Unrelated Operating Room Procedures (CMG 900-906). If there are no procedures reported on the patient’s abstract, the patient will be assigned to the medical partition of the MCC which groups patients on the basis of clinical diagnoses. Yes Yes Yes Assign MCC Based O.R. on Most responsible Procedure In MCC Surgical Partition Procedure Diagnosis No No Unrelated O.R. Medical Partition Procedure 30/11/2018

MCC into Case Mix Groups 30/11/2018 MCC into Case Mix Groups Grouping similar types of patients and or resources together into CMGs 30/11/2018

Most Responsible Diagnosis 30/11/2018 Most Responsible Diagnosis It is the one diagnosis or condition that can be described as being most responsible for the patient’s stay in hospital If there is more than one such condition, the one held most responsible for the greatest portion of the LOS or greatest use of resources should be selected If no diagnosis was made, the main symptom, abnormal finding or problem should be selected as MRDx 30/11/2018

30/11/2018 Patient was playing hockey at an arena when he was struck by another player’s stick, falling on his right arm. He sustained a 5 cm laceration on his head. He also experienced pain in his right arm. In hospital he had a CT scan of his head which was normal. X-ray of his right arm revealed a fracture of the ulnar shaft. He was taken to the OR for fixation of the radius with a plate. The laceration was also sutured. 30/11/2018

Which condition would be the MRDx? 30/11/2018 Which condition would be the MRDx? Laceration of the scalp Fracture of the radius Why? 30/11/2018

30/11/2018 Patient presents to hospital with acute chest pain. After being admitted to hospital for observation and diagnostic testing (heart catheterization and ECG) no definite cause could be found. The chest pain gradually resolved and the patient was discharged. 30/11/2018

30/11/2018 What is the MRDx? If no definite diagnosis is made, the main symptom, abnormal finding or problem should be selected as MRDx. 30/11/2018

Choosing between two or more diagnosis of equal importance 30/11/2018 Choosing between two or more diagnosis of equal importance Acute Gastritis Acute Duodenitis Acute Bronchitis 30/11/2018

Diagnosis of equal importance 30/11/2018 Diagnosis of equal importance When two or more diagnosis of equal importance are listed No clear indication as to which one is MRDx Select the condition for which a definitive (as opposed to diagnostic) surgical or non-surgical procedure has been performed If no surgery performed select the first-listed diagnosis as the MRDx 30/11/2018

Specificity Peptic Ulcer Disease Chronic Bleeding Duodenal Ulcer 30/11/2018 Specificity Peptic Ulcer Disease Chronic Bleeding Duodenal Ulcer Cerebrovascular Accident Cerebral hemorrhage 30/11/2018

30/11/2018 Specificity When the “main” diagnosis describes a condition in general terms Select a more precise code about site or nature if there are more descriptive terms reported among the “other” diagnosis 30/11/2018

Using Diagnostic Test Results 30/11/2018 Using Diagnostic Test Results Patient was admitted for skin lesion. Pathology report showed squamous cell carcinoma 30/11/2018

Using Diagnostic Test Results 30/11/2018 Using Diagnostic Test Results Use Laboratory, X-ray, Pathology, Other diagnostic results When they clearly add specificity to diagnosis/conditions documented din physician’s note 30/11/2018

Inappropriate application of Diagnostic Tests 30/11/2018 Inappropriate application of Diagnostic Tests Microbiology report positive for micro-organism growth No documentation in physician’s notes identifying diagnosis or treatment for urinary tract infection CT scan reveals adhesions of the abdomen No documentation in physician’s notes identifying it as the cause of abdominal pain 30/11/2018

Acute on Chronic Condition 30/11/2018 Acute on Chronic Condition Acute on chronic cholecystitis Acute exacerbation of chronic obstructive pulmonary disease 30/11/2018

Acute on Chronic conditions 30/11/2018 Acute on Chronic conditions Where MRDx is both acute/subacute & chronic If there is no combination code for acute on chronic then acute condition should be coded first The chronic condition is a diagnosis type 3 30/11/2018

Impending or Threatened Condition 30/11/2018 Impending or Threatened Condition Threatened abortion Stage 4 decubitus ulcer. Documentation by physician states impending gangrene 30/11/2018

Impending or threatened condition 30/11/2018 Impending or threatened condition If a threatened or impending condition Is documented Did not occur during the episode of care Check the lookup for terminology such as “impending or threatened” under the main term If such as index exists assign appropriate code If it doesn’t exist than the condition described as impending or threatened should not be coded Code to the precursor condition 30/11/2018

Suspected condition/ Query diagnosis 30/11/2018 Suspected condition/ Query diagnosis Chest pain, Query Myocardial Infarction Query Multiple Sclerosis 30/11/2018

Suspected condition/Query Diagnosis 30/11/2018 Suspected condition/Query Diagnosis If no definite diagnosis has been established by the end of an episode of health care Code the information that permits The greatest degree of specificity and knowledge The condition that necessitated care of investigation 30/11/2018

30/11/2018 If, after an episode of health care, the MRDx is still recorded by the physician as “suspected”, “questionable”, etc and there is no further information or clarification Code the suspected diagnosis as if it were established Use the prefix “Q” in these circumstances whenever available. If the condition has been ruled out after investigation use Z03.~ Medical observation and evaluation for suspected diseases & conditions 30/11/2018

(Q)I21.9(3) Query Myocardial Infarction 30/11/2018 R07.4 (M) Chest pain (Q)I21.9(3) Query Myocardial Infarction (Q) Query Multiple Sclerosis (M) 30/11/2018

30/11/2018 Sequelae Late effect of cerebrovascular accident now hospitalized for treatment of dysphagia 30/11/2018

30/11/2018 Sequelae Conditions that are no longer present as the cause of a current problem undergoing treatment or investigation Code the presenting condition as MRDx Code the sequelae of the underlying condition with a diagnosis type 3 30/11/2018

Admissions from Emergency Room 30/11/2018 Admissions from Emergency Room Diagnosis of each abstract (emergency & inpatient record) Must accurately reflect the circumstances for or treatment provided during that episode of care If treatment started in ER and patient was admitted The identified condition must be recorded as MRDx 30/11/2018

If no definite treatment for injury or condition occurs in the ER 30/11/2018 If no definite treatment for injury or condition occurs in the ER And no reason is given for why the patient was admitted Assume that it was for continuation of treatment of presenting condition 30/11/2018

Summary of MRDx Rules Diagnosis of Equal Importance Specificity 30/11/2018 Summary of MRDx Rules Diagnosis of Equal Importance Specificity Using Diagnostic Test Results in Coding Acute and Chronic Conditions Impending or Threatened Conditions Underlying Symptoms Or Conditions Suspected Conditions/Query Diagnosis Sequelae Admissions from Emergency Department 30/11/2018

30/11/2018 CMG/MCC Assignment Complexity Levels RIW 30/11/2018

Diagnosis Typing – a 1 digit code 30/11/2018 Diagnosis Typing – a 1 digit code To indicate the relationship of the diagnosis to the patient’s stay in hospital Required for every ICD-10-CA code recorded on the Discharge Abstract Database (DAD) (inpatients) To differentiate conditions that influence the patient’s stay from those that do not To flag post-admission comorbidities To use in complexity assignment for CMG 30/11/2018