1.14 Assign MS-DRG and APC groupings-Competency I.5 (Blooms 3)

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Northwest Arkansas Community College *

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2543

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Mechanical Engineering

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Jan 9, 2024

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Uploaded by mandijeanie

Kim is an HIM instructor at a local community college where she teaches courses related to coding and reimbursement. Last semester, students had trouble with the concept of how coding impacts MS-DRG assignment, so she created the following examples to illustrate the concept. This semester, the issue is how and when it is appropriate to bypass an edit related to CPT coding and APCs. Follow the instructions given to gain a deeper understanding of these coding and reimbursement concepts. 1. Identify the MS-DRG for the following scenario: A 78-year-old female is discharged home with the following diagnoses: ● Principal Dx for acute systolic, CHF: I50.21 ● Additional Dx : Lupus (SLE) M32.9 , Insulin-dependent type 1 diabetes uncontrolled E10.65 MS-DRG _ 293 __ 2. If the same patient also had a diagnosis of an acute exacerbation of COPD, what is the MS-DRG? MS-DRG __ 292 __ 3. If the patient in the first example also had a diagnosis of gram-negative pneumonia, what is the MS-DRG? MS-DRG __ 291 __ 4. Now, consider that the same patient in the first scenario had to have a total system, open biventricular pacemaker inserted in the chest while admitted, with leads into the right atrium and ventricle inserted percutaneously. What MS-DRG do you get now? MS-DRG __ 244 __ (Allocated by the diagnoses from #1 in conjunction with PCS codes 0JH606Z, 02H63JZ, 02HK3JZ) 5. A 72-year-old male has an ESWL performed for a right renal calculus. At the same operative session, the same physician removes a malignant lesion from his back resulting in a 3 cm. defect, and performs an intermediate repair. a. Provide the CPT codes that should be assigned for this case along with their corresponding APC: CPT 50590-RT APC 05374 CPT 11603 APC 05071 CPT 12032 APC 05052 b. When this case is coded using the encoder, an edit is given. Explain the edit. “Edit 0040 OCE-NCCI”. CPT 11603 and 12032 are both listed with status indicator N which indicates that the payment is packaged into another procedure. As CPT codes 11603 and 12032 were billed without separate

procedure modifiers, they are considered a component of CPT 50590 and cannot be reimbursed separately without the appropriate modifier. CPT 11603 is an inclusive procedure to CPT 12032, therefore there is no edit needed on the code since no reimbursement is expected. c. Identify if you should bypass the edit and, if so, the step(s) that would be required. This edit can be bypassed to support proper reimbursement from the carrier because CPT 12032 was performed as a separately identifiable procedure apart from CPT 50590. According to the CMS coding guidelines, NCCI PTP-associated modifiers can be used to bypass an NCCI PTP edit if the proper criteria for the use of the modifiers are met. Medical documentation must support the use of the modifier. Modifier XS represents a distinct service when it is performed on a separate organ/structure. By adding modifier XS to CPT 12032, it will properly separate the code from the principal procedure and identify that the repair was done on a separate structure. Since a better-established modifier is appropriate, it should be used rather than modifier 59. CMS states that “Only if there is not a more descriptive modifier available, and the use of modifier 59 best explains the circumstances, modifier 59 should be used”. References AHIMA. (n.d.). 3M Coder . 3m-usa.ahima.org. Retrieved October 13, 2023, from https://3m-usa.ahima.org/launchCRS.html MLN1783722 - Proper Use of Modifiers 59, Xe, XP, XS, and Xu , www.cms.gov/files/ document / mln1783722-proper-use-modifiers-59-xe-xp-xs-and-xu.pdf. Accessed 1 Dec. 2023.

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