Homogeneity of resource use

Clinically meaningful

Practical number of classes

Based on routinely available data

(Fetter et al, 1991)

General principleGeneral principle MajorMajorDiagnosticDiagnosticCategoryCategory

OR ProcedureOR Procedure

DRGDRG

PrincipalPrincipalDiagnosisDiagnosis Secondary Secondary

DiagnosesDiagnoses

Age, Age, Discharge type,…Discharge type,…

ICD-9-CMICD-9-CM

ICD-10ICD-10

1/14

Severity refined(AR-DRG concept)

• Bilateral /Multiple procedures• Coding: ICD-10 2007+ICD-10-TM (Dx)

ICD-9-CM 2007 with Extension

Complete ICD-10/ ICD-9-CM library

HCFA DRG Commonly used

ICD code only

2012

1,283

511

511

1,920

2,450

1998

2003

2001

2007

Version Refined Diagnosis code

Procedure code Groups Implement

1 NoICD-10 (WHO)

1992ICD-9-CM

2000 511 Nov 1998

2 No ICD-10 (WHO) 1992

ICD-9-CM 2000 511 Feb 2001

3

3.0 5 levels ICD-10 (WHO) 1992

ICD-9-CM 2000 1,283 Oct 2003

3.1 5 levels ICD-10 (WHO) 1992

ICD-9-CM 2000 1,283 Apr 2005

3.3 5 levels ICD-10 (WHO) 2005

ICD-9-CM 2005 1,283 Feb 2006

3.5 5 levels ICD-10 (WHO) 2005

ICD-9-CM 2005 1,467 -

4 5 levelsICD-10 (WHO)

2007 + ICD-10-TM*

ICD-9-CM 2007

with extension1,920 Oct 2007

5 5 levelsICD-10 (WHO)

2010 + ICD-10-TM*

ICD-9-CM 2010

with extension2,450 Apr 2012

* For data entry only (not for new classification)

ICDICD--1010

Volume 2Instruction manual

Version for 2010

Volume 1Tabular list

Volume 3Alphabetical

index

ICDICD--1010--TMTM

Volume 1Tabular list

Volume 2Index

Thai modification

2/14

Diseases

Injuries

Symptoms

Reasons for encounter

Factors that influence health status

External causes of disease

MortalityMorbidity

Main diagnosis that need medical care of this admission

Must be disease or condition that present before admission

PregnancyPregnancy, , childbirth & childbirth & perpeureumperpeureum

NeonatesNeonates

HIV HIV

CancerCancer3/14

Disease or condition other than PDxMay be Comorbidity or Complication but must be the problem that need medical care during the admission

“Comorbidity” or “Complication”(not “Other diagnosis”)ICD-10 WHO or ICD-10-TM ThaiDRG v4 allows only 12 codes

SDxSDx ((CCs) CCs)

Not used for DRG refinementNot used for DRG refinement

Not used for DRG groupingNot used for DRG groupingbutbut must be coded for must be coded for

reimbursement in reimbursement in ‘Accident’ cases (NHSO) ‘Accident’ cases (NHSO)

PDxPDx

DRG RW WTLOS OT OF Description04520 0.6156 4.63 14 0.57 Respiratory infection/inflammation, no CC

04521 0.7143 5.14 16 0.76 Respiratory infection/inflammation, w mild CC

04522 1.0663 6.47 21 0.63 Respiratory infection/inflammation, w mod CC

04523 1.6098 8.11 29 0.87 Respiratory infection/inflammation, w severe CC

04524 3.5153 11.84 46 1.00 Respiratory infection/inflammation, w catastrophic CC

4/14

Non-OR procedure

Non-OR procedure affect DRG

OR procedure

•• RadiosurgeryRadiosurgery•• ExtractionExtraction & & restorationrestoration, , toothtooth•• ContinuousContinuous mechanicalmechanical ventilationventilation•• CardiacCardiac diagnosticdiagnostic procedureprocedure•• SkinSkin & & subcutaneoussubcutaneous tissuetissue procedureprocedure•• EndoscopeEndoscope•• PlasmapheresisPlasmapheresis•• TracheostomyTracheostomy

720 Low forceps operation721 Low forceps op w episiotomy7221 Mid forceps op w episiotomy7229 Other mid forceps operation7231 High forceps op w episiotomy7239 Other high forceps operation724 Forceps rotation of fetal head7251 Partial breech ext w forceps7252 Other partial breech extraction7253 Total breech ext w forceps7254 Other total breech ext w forceps7271 Vacuum extraction w episiotomy7279 Other vacuum extraction7321 Internal & combined version wo ext7322 Internal & combined version w ext733 Failed forceps7351 Manual rotation fetal head

7359 Other manual assist delivery738 Op on fetus to facilitate delivery7391 External version7392 Replaced prolapsed umbilical cord750 Intra-amniotic injection for abortion751 Diagnostic amniocentesis752 Intrauterine transfusion7531 Amnioscopy7533 Fetal blood sampling & biopsy7537 Amnioinfusion754 Manual removal of retained placenta7562 Repair current OB laceration rectum7569 Rep oth curr OB laceration757 Manual explore uterine cavity, PP7591 Evac OB incision hematoma perineum7592 Evac other hematoma vulva/vagina7594 Manual replacement of inverted uterus

5/14

0102 Ventriculopunct thru cath0109 Other cranial puncture0331 Spinal tap247 Applic orthodont appliance3404 Insertion of ICD3491 Thoracentesis3891 Arterial catheterization3892 Umbilical vein cath3893 Venous catheterization3894 Venous cutdown5491 Paracentesis5711 Percutan bladder aspirat5751 Excision of urachus5794 Insert indwelling cath598 Ureteral catheterization8191 Arthrocentesis8321 Soft tissue biopsy8611 Skin & subq biopsy8659 Skin closure NEC

8703 C.A.T. scan of head8741 C.A.T. scan of thorax8801 C.A.T. scan of abdomen8871 Diag US of head & neck8872 Diag US of heart8875 Dx ultrasound-urinary8876 Dx ultrasound-abdomen8891 MRI of brain & brainstem9390 CPAP9391 IPPB9608 Insert intestinal tube9623 Dilation anal sphincter9635 Gastric gavage9671 Cont mech vent < 96 hrs

9901 Exchange transfusion9903 Whole blood transfus NEC9904 Packed cell transfusion9905 Platelet transfusion9906 Coag factor transfusion9907 Serum transfusion NEC9909 Transfusion NEC9914 Inject gamma globulin9915 Parent infus nutrit sub9960 Cardiopulm resuscitaton9962 Oth elec countershock hrt

Closed biopsyClosed biopsySpecial investigationSpecial investigation CT scan CT scan MRIMRI U/S,…U/S,…

Blood (& components) transfusionBlood (& components) transfusion9903 Whole blood transfusion NEC 9904 Packed cell transfusion 9905 Platelet transfusion

99.2-, 99.3- Therapeutic radiology 99.25 Inject. cancer chemotherapy

Z51.0 Radiotherapy sessionZ51.1 Chemo℞ session for neoplasm

99.03 Whole blood transfusion99.04 Packed cells transfusion99.05 Platelets transfusion

Closed biopsy, Special X-ray, US, CT, MRI, Nuclear scan,…

6/14

9427 Other electroshock therapy (MDC 19)

9851 ESWL: kidney/ ureter /bladder (MDC 11)

9910 Thrombolytic injection / infusion (MDC 5)

9920 Platelet inhibitor injection/infusion (MDC 5)

* ESWL = Extracorporeal shock wave lithotripsy

99 9 9 9 99+

Example Phacoemulsification & aspiration of cataract both eyes in the same operation.

1

2 sides1st

operation

3 4

Phacoemulsificationand aspiration of

cataract

1 12+1 3 4 1 11+

1 3 4 1 21+

Example Phacoemulsification & aspiration of cataract both eyes in 2 operations.

7/14

DC Desc0112 Craniotomy (multiple) for trauma0113 Craniotomy (multiple),0211 Multiple major lens procedures0212 Multiple other lens procedures0536 Multiple wound debridement (in CVS)0801 Bilateral or multiple major joint proc of lower ext0828 Multiple (2-4) wound debridement w skin graft except

hand for MS&CT0830 Multiple (2-4) wound debridement for MS&CT0836 Multiple (>4) wound debridement for MS&CT0910 Skin graft and multiple debridement for ulcer or cellulitis2417 Multiple wound debridement for MST

RW

DRG

Non OR Procedure

ORProcedure

Secondary diagnosis 1

Principal diagnosis

Secondary diagnosis 2

0.2727

01670Other Head injury, no CC

--

--

Head injury(S099)

Summary 1

1.0973

01650Intracranial injury, no CC

--

--

Acute subdural

hematoma (S065)

Summary 2

3.9029

01010Craniotomy for trauma, no CC

--

Removal of subdural

hematoma (0131)

Acute subdural

hematoma (S065)

Summary 3

6.2971

01013Craniotomy for trauma, with severe CC

--

Removal of subdural

hematoma (0131)

Pneumonia (J189)

Acute subdural

hematoma (S065)

Summary 4

01163Trach for NS disease, w mild to sev CC

Tracheostomy(311)

22.5935

Removal of subdural

hematoma (0131+21)

Acute subdural

hematoma (S065)

Summary 6

Pneumonia (J189)

10.8629

01129Craniotomy (multiple) for trauma, with or wo CC

Removal of subdural

hematoma (0131+21)

Pneumonia (J189)

Acute subdural

hematoma (S065)

Summary 5

--

ICD as classification

Coding rules

Coding quality

Upcoding

8/14

ICDICD--1010

Volume 1Tabular list

Volume 2Instruction manual

Volume 3Alphabetical

index

“The condition, diagnosed at the end of the episode of health care, primarily responsible for the patient’s need for treatment or investigation.If there is more than one such condition, the one held most responsible for the greatest use of resources should be selected.”

Reason for admission Resource

Diagnosis that either co-exists with the main diagnosis at the time of admission, or which appears during the episode of care.

Other conditionOther condition

9/14

Dagger Dagger † / Asterisk / Asterisk *Dual Codes (Dual Codes (1 1 DxDx 2 2 codes)codes)

• 2 dimensions of disease– Cause (Etiology) – Effect (Manifestation)

• Code Dagger first Asterisk

Tuberculous meningitis

Tuberculousmeningitis

Meningitis in bacterial diseases

classified elsewhere

A17.0† G01*

Bureau Policy and Strategic, MoPH

10/14

If the patient had been previously diagnosed with heart disease such as Mitral stenosis, Tetralogy of Fallot with congestive heart failure, etc. The principal diagnosis should be Congestive heart failure, followed by heart disease as comorbidity.However, if a patient with congestive heart failure and was diagnosed heart disease for the first time. Select heart disease to be principal diagnosis and congestive heart failureas a comorbidity.

Physician should diagnoses Congestive heart failure, in specific term as left ventricular failure, right ventricular failure secondary to left ventricular failure, biventricular failure or right ventricular failure.

Patients with symptom of severe dyspnea. Chest radiography showed infiltration in both lungs and was diagnosed as acute pulmonary edema.

If heart disease was the cause, The diagnosis was acute cardiogenic pulmonary edema or acute left ventricular failureif it caused by other heart disease, e.g. drug, patient should be diagnosed as acute non-cardiogenic pulmonary edema.

If diagnosed as Right ventricular failure secondary to left ventricular failure, Biventricular failure or Right ventricular failure, code I50.0 Congestive heart failure.

If diagnosed as Left ventricular failure or Acute cardiogenic pulmonary edema, code I50.1 Left ventricular failure.

If diagnosed only Heart failure. code I50.9Heart failure, unspecified.

11/14

MisMis--specificationspecification Invalid Diagnosis summaryInvalid Diagnosis summary

MisMis--coding coding UpcodingUpcoding

ResequencingResequencing Incorrect Incorrect PDxPDx//SDxSDx

sequencing by codersequencing by coder

OtherOther e.g. Age data e.g. Age data

Simborg, D.W., "DRG Creep: A New Hospital-Acquired Disease," N Engl J Med, June 25, 1981, 304(26), pp. 1602-1604.

AuditAudit

• Control mechanism• Scheme oriented

– UC Coding audit, Clinical audit– CSMBS Billing, Quality of care

+Coding audit-- SS Coding audit (begin 2013)

• System audit + Medical record audit

Inpatientcare

In-patientSummary

Coding(ICD-10,

ICD-9-CM)

StandardData set

DRG’sDRG’sDRG’sDRG’s

DRG GROUPER

11

22

Coding auditCoding audit

12/14

Quality auditQuality audit• OPD card• Discharge summary• History, Physical examination• Progress note• Doctor’s order• Operative note in surgical case• Anesthesia record• Vital ’s sign record• Nurse admission note• Nurse’s note (progress and others)• Medication record

Database

Acute Duodenal ulcer w hemorrhage

HypernatremiaPseudomonas pneumonia-Acute Posthemorrhagic anemia

Liver cirrhosis

Coding auditCoding audit

0 No disagreement1 Principal diagnosis ( PDx )

1a Missing PDx1b Invalid PDx1c Non-specific PDx

2 Additional diagnosis (Comorbidity & Complication: CC )

2a Missing CC2b Invalid CC2c Non-specific CC2d Unjustified CC

3 Operative (Op)3a Missing Operation3b Invalid Operation3c Non-specific Operation 3d Unjustified Operation

5 Not –summarized6 Other problems

0 No disagreement1 Principal diagnosis (PDx)

1a Missing PDx code1b Invalid PDx code1c Non-specific PDx code

2 Additional diagnosis (Comorbidity & Complication: CC ) 2a Missing CC code2b Invalid CC code2c Non-specific CC code2d Unjustified CC code

3 Incorrect Operation code3a Missing Operation code3b Invalid Operation code3c Non-specific Operation code3d Unjustified Operation code

6 Other problems

13/14

2006 2007 2008 2009 2010 2011

Method Random Random Random Selected Selected & Random Selected

N % N % N % N % N % N %

Target 1,434100

59,897100

65,289100

34,830100.7

43,621100.7

54,687103.2

59,897Result 1,434 65,289 35,073 43,901 56,410

Errors (Charts)

620 43.2 39,414 65.8 40,227 61.6 30,582 87.2 39,693 90.4 51,622 94.4

Summaryerror 43.3 55.1 52.4 82.8 80.8 81.9

Coding error 58.4 63.1 60 89.5 88.5 90.3

Others - - 4.1 6.3 8.1 10.6

AdjRW change 106 1,001 261 -13,037 -18,583 -19,805

*N = Number of charts

2006 2007 2008 2009 2010 2011

Method Random Random Random Selected Selected & Random Selected

N % N % N % N % N % N %

Target 1,434100

59,897100

65,289100

34,830100.7

43,621100.7

54,687103.2

59,897Result 1,434 65,289 35,073 43,901 56,410

Errors (Charts)

620 43.2 39,414 65.8 40,227 61.6 30,582 87.2 39,693 90.4 51,622 94.4

Summary error 43.3 55.1 52.4 82.8 80.8 81.9

Coding error 58.4 63.1 60 89.5 88.5 90.3

Others - - 4.1 6.3 8.1 10.6

2006 2007 2008 2009 2010 2011

Method Random Random Random Selected Selected & Random Selected

N % N % N % N % N % N %

Target 1,434100

59,897100

65,289100

34,830100.7

43,621100.7

54,687103.2

59,897Result 1,434 65,289 35,073 43,901 56,410

2006 2007 2008 2009 2010 2011

Method Random Random Random Selected Selected & Random Selected

Bureau of Claim and Medical Audit :NHSO

20112011Selected Random

N % N %

Target 54,687103.2

3,045100

Result 56,410 3,045

Error (Charts) 51,622 94.4 1,999 65.7

• Summary errors 81.9 58.7

• Coding errors 90.3 64.4

• Other 10.6 4.7

Bureau of Claim and Medical Audit :NHSO

• Severe CC level but low LOS & expense (Charge)

• High RW but low LOS & expense

• DRG with Continuous mechanical ventilation/ Craniotomy but low expense

• OR Procedure unrelated to Principal Diagnosis

• ……Bureau of Claim and Medical Audit :NHSO

14/14