The PILOT MS-DRG Grouper is available now in the following MediRegs products: Compliance & Regulation Suite, Audit & Revenue Resource Center and Coding & Revenue Resource Center. On the left-hand navigation pane, under Lookup and Payment Tools, notice 2 different links; the pilot version is marked "ICD-10", and it should be understood that this logic is for testing and predicting. Use the original grouper for current year ICD-9 grouping logic.
CMS decided to release the v28 ICD-10 Pilot MS-DRG grouping logic into the public domain because "CMS believes this software will allow the public to more easily review and provide feedback on updates to the ICD-10 MS-DRGs."
Members of our Coding Suite Advisory Board have been trying out the pilot grouper for a few months now, and we are finding lots of places where grouping logic does not seem to behave as we'd expect. The question for the industry is - are these errors, or intentional changes?" Regardless of the answer, as you run sample claims through the grouper, if you find results that do not behave as you'd expect, you should provide feedback directly to CMS:
1 - Send an email directly to Pat Brooks (patricia.brooks2@cms.hhs.gov). Copy/Paste the text or attach a screen shot of the grouper results from the screen in the Coding or Compliance Suite product you use.
2 - CC us, so that we can look at the issue as well. Rayellen.Gilles@WoltersKluwer.com.
3 - Consider posting your results in the comments attached to this blog post for discussion. Click the link at the bottom.
Comments
Normal Birth Example
Here is an example:
Scenario is a Normal male newborn that has a circumcision and Hepatitis B vaccination while in the hospital.
ICD-9 Codes
Birth, Vaccination and Circumcision coding (V30.00, V50.2/64.0, V05.3/99.59)
groups to MS-DRG 795 Normal newborn
ICD-10 Codes
If you enter the newborn and the circumcision codes
(Z41.2/0VTTXZZ) it groups as expected to MS-DRG 795 Normal newborn.
But if you add in the vaccination codes
(Z23/3E0234Z)
it groups to a much Higher relative weight MS-DRG 794 Neonate w other significant problems.
Here are the FY2012 national unadjusted rates for these:
795 $932.52 NORMAL NEWBORN
794 $6,885.22 NEONATE W OTHER SIGNIFICANT PROBLEMS
Surely, CMS does not mean to pay nearly $5K more because a vaccine was administered?