Q&A: Base MS-DRGs and the newborns/other neonates MDC

Q: If the patient is a Medicare beneficiary, why wouldn’t a MS-DRG associated with the newborns and other neonates major diagnostic category (MDC) not be used? Is it because the patient is more than likely 65 (since they are a Medicare beneficiary) and this MS-DRG is for a newborn/neonate or because the patient (if he/she was a newborn) would have to have a certain disability or have end-stage renal disease (ESRD)?

A: You’re on the right path. For a person to qualify for Medicare, they have to meet certain criteria, the first being age 65, we call this “aging into the system.” A disability can also qualify a person for Medicare, ESRD is an example of a disease process that will qualify a patient for coverage under Medicare. Medicare pays for the care using the MS-DRG (Medicare-Severity Diagnostic Related Group), under the Inpatient Prospective Payment System (IPPS).

There are other payment systems out there. You’ll likely hear a lot about the All Patient Refined-Diagnosis Related Groups (APR-DRG) system as well. This system can be used in conjunction with the MS-DRG system or by itself. Some states (i.e. Maryland) only use the APR-DRG system. The APR-DRG gives us information regarding a patient’s severity of illness (SOI) and their risk of mortality (ROM). One of the biggest differences in the systems is that MS-DRGs use the addition of MCC/CC to allow for movement between the different levels of a DRG type, where APR-DRGs does not.

As a bit of history, originally CDI specialists did not review certain patient populations, including mother/baby or the neonatal intensive care unit (NICU). The focus or mission of the early CDI departments were usually financial. Mother/baby and NICU patients usually didn’t have an extensive past medical history, so the capture of comorbidities classified as either CC/MCCs was very slim.

Now, CDI has moved into more of a dual role, incorporating both financial and quality measures related to documentation. With that shift, CDI has started reviewing other types of patients’ charts for non-financial benefits.

Editor’s Note: Sharme Brodie RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.