Coding Q & A with ECLAT Expert – Marie Thomas

Question:

J96.00 (Principal DX) – Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
S06.6X6A (Admitting DX) – Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
00N.00ZZ (Principle Procedure Code- ICD-10-PCS) – Release Brain, Open Approach
What would be the appropriate APR DRG, is it 020-1, 020-2, 020-3 or 020-4 or something else?

Answer:

All Patient Refined Diagnosis Related Groups (APR-DRGs) are similar to Medicare Severity Diagnosis Related Groups (MS-DRGs) in that they are calculated from a preassigned numerical weight listing – multiplied by a fixed dollar amount based on each individual provider.  The base rate of APR-DRG is derived from how sick the patient is via codes assigned, considering the severity of illness and the risk of mortality.  APR-DRGs are unlike MS-DRG’s in that the base rate for MS-DRG is calculated from the codes assigned from a single complication or comorbidity.  Medicare groups claims using MS-DRG for reimbursement.  Some Medicaid, Workers compensation, no fault and commercial payers group to APR-DRG for reimbursement.  3M developed the APR-DRGs version (v#) and provide updates annually.  It is important to work with payers to understand the APR-DRG listing and weights.

Using the 3M APR-DRG grouper Version 18.3.1.0 (131), PDX J96.00 admitting DX S06.6X6A PCS 00N00ZZ, the APR DRG is 950 SOI = 1 ROM = 2 (a relatively low risk patient based on the coding)

If the documentation supports the PDX J96.00 admitting DX S06.6X6A and secondary diagnosis S06.6X6A with the PCS 00N00ZZ the APR DRG is 10 and the SOI = 3 and ROM = 4 (these codes reflect a much sicker patient with risk of dying).

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