Diagnosis Related Groups - Assignment Example

DRG 468 thus pays for discharge in which the patient undergoes an operating room procedure entirely unrelated to this admission's principal diagnosis. This is against the PPS classification of discharges of clinically coherent groups. Although this is possible in some cases, DRG 468 can be an example of DRG creep. The attending physician may misspecify the principal diagnosis, secondary diagnosis, or the procedure on the attestation sheet. It can also be the result of miscoding, where the hospital assigns an incorrect numeric code to the diseases or procedures which had been correctly attested by the physician in charge.

In some cases to avoid investigation, the hospital may substitute a secondary diagnosis for the correct principal diagnosis. Therefore for an appropriation of facts, auditing and review are necessary that would identify discharges in which coding rules are either ignored or not applied appropriately. DRG 468 is assigned when all the operating room procedures are unrelated to the major diagnostic category for which the patient had been admitted. Most often, these patients are admitted with a principal diagnosis that does not need any surgery.

 To assess the appropriateness, the ICD-9-CM coding guidelines should be applied to do the initial coding and for auditing if such has been used. The principal diagnosis is always the reason for admission, which should be backed by records indicating circumstances at admission, diagnostic workup, and therapy provided. The scenario is not an admission of the patient to treat two conditions, it is rather two conditions present during admission. While auditing and reviewing, it is to be determined whether the principal diagnosis was the reason for admission and treatment.

If at admission, there were more than one diagnosis, the use of guidelines for selecting the principal diagnosis would be used with consideration of circumstances at admission, diagnosis workup, and the therapy provided. The principal procedure must be performed for definitive treatment, not for diagnostic purposes, exploratory purposes, or for a complication. If there are two procedures done, then the one most related to the principal diagnosis would be selected as the principal procedure. The procedure must be significant as defined by the Uniform Hospital Discharge Data Set would be used, and for this to qualify, it must be surgical under anesthesia with the operator being specially trained.

The audit must look at the detailed documentation in the medical record. There must be enough proof and substantiation that it was medically necessary. The coding should be done from the narrative description of the procedure, not from the written title of the procedure. The approach and closure of the procedure are an integral part of one significant procedure, not two separate.