Coding, Classification and Reimbursement

Addition of EXCISION root operation changes DRG, lowers RW

  • 1.  Addition of EXCISION root operation changes DRG, lowers RW

    Posted 12-31-2018 02:40

    Principal dx = M12.812

    Original procedure performed and principal procedure = removal of humeral head device from a hemi shoulder 0RPK0JZ, replacement with humeral and glenoid components for a reverse shoulder 0RRK00Z, DRG 483, RW 2.3835.

    Additional procedure performed later during the stay = excision of a lesion in the subQ of the right thigh 0JBL0ZZ, which changed the DRG to 465, RW 1.8374.

    I ran this through our standalone encoder as well as 3M, with the same result.

    This doesn't make sense to me. Why would the addition of the lesion excision procedure change the DRG from 483 (which has a higher RW) to 465 (which has a lower RW)? If anything, I would expect the DRG to remain the same or possibly cause an increased RW, but not reduce it.

    Am I missing something obvious? Am I using 3M wrong? Is there some rule about the EXCISION root operation that everyone but myself is aware of?



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    Amy Dael
    Coder
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  • 2.  RE: Addition of EXCISION root operation changes DRG, lowers RW

    Posted 01-02-2019 10:04
    ​Was the removal of skin lesion for diagnostic purposes? If so, code 0JBL0ZX instead of 0JBL0ZZ would take you back to DRG 483.

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    Crystal Crafts, RHIT CCS
    Coding Manager
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  • 3.  RE: Addition of EXCISION root operation changes DRG, lowers RW

    Posted 01-03-2019 20:44
    Edited by Amy Dael 01-03-2019 21:31
    Thank you for bringing this up. The op report did indeed call it a biopsy, but since the entire lesion plus margins was removed, and because it was not sent to pathology for identification, we did not feel it truly was a biopsy.​ However, after considering your comment, we realized that we were thinking in CPT terms instead of PCS terms. What is diagnostic purpose? Well, to identify the lesion. If it could be identified by the surgeon visually (which it was) without being sent to pathology, then the lesion was identified, whether or not it was partially or fully excised. So perhaps it does fulfill the criteria for X diagnostic. Thanks!

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    Amy Dael
    Coder
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  • 4.  RE: Addition of EXCISION root operation changes DRG, lowers RW

    Posted 01-02-2019 10:29
    ​DRG 483 Major Joint/Limb reattachment procedure of upper extremities

    DRG 465 Wound Debridement and Skin Graft except hand for MS system and Connective Tissue Disorders w/o CC/MCC RW 1.8374

    Some observations...
    • DRG 483 is by itself and is not impacted with a CC/MCC or lack of either
    • DRG 465 is a triplet:  464 w/CC RW 2.9440;  463 w/MCC RW 5.1319
    • It is not that you adding the additional procedure changed the DRG necessarily because each time you enter all of the applicable codes 3M (or any encoder) follows the DRG logic to determine the DRG represented by those codes.  If you concurrently code, which it sounds like you do you can easily get a DRG that is not the same as what you will get at Discharge after all of the coding has been performed.
    The point made by the other respondent is a good one - the intent of a procedure can change the impact of a procedure in the DRG logic.

    Hope this helps.


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    Kathy Completa
    Coding and Documentation Educator
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  • 5.  RE: Addition of EXCISION root operation changes DRG, lowers RW

    Posted 01-03-2019 20:49
    I was able to contact 3M Nosology, who explained to me that​ DRG 465 is higher in the CMS surgical hierarchy than DRG 483, despite the fact that 483 is the higher relative weight. So it is what it is, and 465 trumps 483 for that reason. Thanks for your thoughts!

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    Amy Dael
    Coder
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