Determine MS-DRG shifts ahead of ICD-10
ICD-10 implementation will arrive very soon, and many facilities are putting the final touches on their preparations. And yet many have not looked at looming MS-DRG shifts.
Various assessments by CMS, Milliman, and 3M found that the MS-DRG assigned to an ICD-10 claim did not always match the MS-DRG assigned to an ICD-9-CM source claim, says Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, an AHIMA-approved ICD-10-CM/PCS trainer with more than 30 years of experience in HIM.
The CMS and 3M studies have determined that overall, approximately 1% of MS-DRGs will shift under ICD-10. "To most of us that seems very, very small," Bryant says.
However, facilities need to break down which MS-DRGs are shifting. "If those shifts are in more common MS-DRGs that we see in our patient population, the impact could be greater," Bryant says.
Of the 1.07% of MS-DRGs that will shift, 41% will shift to a higher-paying MS-DRG, while 66% will move to a lower-paying MS-DRG, according to a CMS study.
CMS has indicated that the MS-DRG payment calculation under ICD-10 will be a replication of the current system, Bryant says. Although CMS has indicated that this change will be budget neutral, there will be some payment redistribution based on the differences between ICD-9-CM and ICD-10.
"The ICD-10 code sets are not just a simple update of ICD-9-CM code sets used currently for reporting patient encounter information, but have changes in structure as well as changes in concepts that make them very different," Bryant says. "Every organization needs to make sure that payments based on ICD-10 must be within an understandable and acceptable variance from that of ICD-9 payments."
Start by identifying your top 25 medical MS-DRGs and your top 25 surgical MS-DRGs, Bryant says. If you don't have time to run that many reports, at least look at your top 10 in each category.
Check how often you report specific MS-DRGs, principal diagnoses, and secondary diagnoses to make sure they are consistent before and after implementation. If the frequency changes, you need to determine the cause.
MS-DRGs will shift for several reasons, says Lori P. Jayne, RHIA, HIM director for Lahey Health System in Burlington, Massachusetts.
Are cases being coded correctly? Is the documentation adequate to capture new/different codes? Did the coding guidelines change?
Four factors affect MS-DRG-based reimbursement between ICD-9-CM and ICD-10:
- Number of discharges for each MS-DRG
- Percentage of time the MS-DRG shifts
- Change in weight for each shift between ICD-9-CM and ICD-10
- Base rate for the relevant payers
"These four factors are vital to more efficiently calculating reimbursement impact under ICD-10," says Bryant.
Editor's Note: This article originally published in the newsletter Briefings on Coding Compliance Strategies.