There are four main elements that are taken into consideration by a DRG grouper software to generate a DRG. These four elements are
1.Surgical procedure codes
2.Diagnosis
3. Discharge Status
4. Patient's age
5. Patient's gender
The surgical procedure codes, the diagnosis, and the patient's age and gender are used to determine the correct DRG assignments. If any one of them is coded incorrectly on the claim form, the resulting DRG will l be wrong. One can understand that primary procedure and diagnosis codes will affect DRGs, but how does patient's age and gender affect DRG?
Some DRG weights are age dependent. For example, if a person younger than 17 is hospitalized for cellulitis, the DRG is 279 and the weight is .7785. If the patient is older then 17 then the DRG is 277 with weight of 0.8877. Patients gender also plays a role if you assign a DRG for pregnancy and the patient is a male. The claim will be rejected.
Coding alcohol and drug abuse and dependence
Alcohol and drug abuse and dependence coding are classified into psychiatric section of ICD and the treatment for these conditions require drug or alcohol rehab. The most confusing part of abuse and dependence coding in ICD is the fifth digit for the type of abuse or dependence. According to coding clinic the fifth digit should be assigned depending upon physician documentation and not on the time frame or pattern of drug or alcohol abuse. The following are the options for fifth digit assignment.
continuous
episodic
remission
unspecified
The selection of fifth digit is based on physician documentation of the words like "continuous", "episodic", and "remission." Even if there is documentation of abuse or dependence of drug or alcohol in the past and still the patient is using the drug/alcohol we cannot assume it as continuous abuse. It should be coded as unspecified abuse as long as the physician documents it as "continuous abuse."
If there is history of alcohol or drug abuse and there is no other documentation of abuse then according to coding clinic we can code it as remission.
continuous
episodic
remission
unspecified
The selection of fifth digit is based on physician documentation of the words like "continuous", "episodic", and "remission." Even if there is documentation of abuse or dependence of drug or alcohol in the past and still the patient is using the drug/alcohol we cannot assume it as continuous abuse. It should be coded as unspecified abuse as long as the physician documents it as "continuous abuse."
If there is history of alcohol or drug abuse and there is no other documentation of abuse then according to coding clinic we can code it as remission.
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