Case #116

Case 2012-MDC03-02 Tonsill and adenoid procedures

Added by Anonymous almost 6 years ago. Updated almost 3 years ago.

Status:AcceptedStart date:2013-11-19
Priority:Error correctionSpent time:-
Target version:Expert Group 2012
Initiator:Sweden Target year:2013
Case type:Major Owner / responsible:National organisations
MDC:MDC03 Old forum status:RE ACTITEM - Closed item reactivated by discussion or due to suggested amendments


Last updated: 2012-11-01

Status: CLOSITEM - Closed item

Initiated: 2011-06-17

By: Denise Olsson, Skåne, Sweden

Expert Network 2012-03-06 - Changed recommended

Board 2012-03-19 - Recommendation accepted

Reactivated 2012-11-05

By: Mats Fernström


CPK ID: 378


It has been reported from NordDRG users that registration of a secondary procedure in addition to a tonsillectomy or adenoidectomy results in a DRG with lower weight. For example the following case was presented:

Patient age <18 years. Principal diagnosis: J353 ‘Hypertrophy of tonsils with hypertrophy of adenoids’. Procedure: EMB30 ‘Adenotomy’. This results in DRG 060 ‘Tonsillectomy &/or adenoidectomy only, age 0-17’. If EMB99 ‘Other excision on tonsils and adenoids´ was added it resulted in DRG 058 ‘T&a proc, except tonsillectomy &/or adenoidectomy only, age 0-17’ with a lower weight.

Analysis by NPK, Sweden

That addition of a secondary procedure results in a DRG with lower weight is mostly wrong and it stimulates under-reporting.

The DRGs and the grouping rules in the ordinary NordDRG that are involved in this problem are listed in the table below, where also the Swedish DRG weights for 2012 have been inserted.

In the CC grouper the age split has been removed but the principle that the combined procedure is higher up in the hierarchy than the isolated procedure remains, although the weight for the combined procedure is lower.

In this actual case, addition of EMB99 (with OR 1 and procpro 03S11) results in a DRG with lower weight, both in ordinary NordDRG and in the CC grouper.

We have discussed different ways to solve the problem.

  • Change the hierarchy so that the rules for the isolated procedure will be placed before the rules fore combined procedures? Then it is also necessary to change in the rules for the isolated procedure (DRG 059, 060 and C21N) and insert a minus sign in the field Secproc1, because otherwise combined procedures will be grouped together with isolated procedures. A minus sign in the field Secproc1 will however cause other problems. Probably a correct registration of the code for general anesthesia will block the grouping of isolated procedures to the DRGs that are meant fore them.
  • Break out the procedures with procpro 03S11 from DRG 057, 058 and C20N? It would not solve the problem because the plus sign in the field Secproc1 of the first rules for these DRGs means that the addition of any procedure with OR 1 still leads to a DRG with less weight.
  • Merge isolated and combined interventions to the same DRG? This means that in ordinary NordDRG merge DRG 057 and 059 and DRG 058 and 060 and in the CC-grouper DRG C20N and C21N are merged. The table below shows the weight differences between the DRGs that would be merged. Since the weights are based on KPP (cost per patient) we can calculate that the largest difference (0.0748) corresponds to a cost difference of about 3 000 SEK, which is quite small in terms of inpatient care. The weight for DRG 060 is only 15% greater than that of DRG 058 so if these groups had already been merged, the criteria for a split should not be fulfilled. The weight difference between the groups in the CC-Grouper (DRG C20N and C21N) is even smaller. A further argument for a merge is that it is questionable whether it is necessary, from a medical description standpoint, to have so many DRGs for procedures on the tonsils and adenoids in inpatient care.

Suggestion by NPK, Sweden

(From 2013 Sweden will use the CC grouper only and therefore we don’t suggest changes in the ordinary NordDRG.) We want the DRGs C20N and C21N to be merged into a new DRG with the code C22N and the text “Operationer på tonsiller och adenoid”. Technically this can be achieved in different ways. We suggest the following:

  • The rule with ord 403D124 is deleted. The corresponding rule for outpatients can also be deleted.
  • In the rules with ord 403D125 and 403D15102 the DRG is changed to C22N.

Thus we deliberately keep the procpro 03S11 which will make it easier to undo these changes in the future, if necessary. The technical changes are specified in the file TECHNICAL CHANGES SWE 2012-02-17.xls.

There is no need to add extra cases to the table TESTRULE but all cases with DRG C20N or C21N have to be regrouped.


Martti Virtanen, NCC 2012-02-28

I support this proposal. This has from the beginning of NordDRG been suspicious grouping but since it follows the US model, it has been retained.

I hope other countries will analyze the proposal for acceptance in the expert group meeting

Expert Network 2012-03-08

The meeting recommends accepting the proposal to merge C20N and C21N to a new DRG C22N and DRG-name "Operation på tonsiller och adenoid".

The case will be closed.

National DRG Centre, Petra Kokko/Minna-Liisa Sjöblom, 20120730

We were studying DRG 57, 59, and 60. DRG 58 has already been removed and those cases will be combined to DRG 60. Age limits are not needed and groups are similar enough.


We suggest that DRG 57 and DRG 59 will be removed and combine the cases to the group DRG 60.

And the name of DRG 60 will be changed to Tonsillectomy &/or adenoidectomy.

Martti Virtanen 2012-10-26

The rules for DRG 060O/C22O group all outpatient cases to this DRG. Therefore there is no need to combine any groups for outpatient part and all current rules have to be retained. Remove of rule ordnr 103D1201 would result in grouping of all cases with tonsillectomy or adenoidectomy wrong since procedure property 03S03 is the only MDC 03 property these interventions have.

We should probably combine properties 03S03 and 03S11 but I would recommend a short analysis whether 03S11 cases should be grouped to some other group than 03S03 since interventions with 03S11 are actually not tonsillectomies or adenotomies. Therefore this further change is not performed now.


NordDRG 2013

Mats Fernström, NPK, Sweden 2012-11-05

The comments dated 2012-07-30 and 2012-10-26 means that the case status should be changed from “closed” to “reactivated”.

We do not agree that “all current rules have to be retained”. The rules with the plus sign in the secproc column are not needed. Patient cases with procpro 03S03 are grouped according to the similar rules without that plus sign.

The name “Tonsillectomy &/or adenoidectomy” on the merged group is somewhat misleading since many other procedures are included as well (those with procpro 03S11). In Sweden we have therefore chosen the name “Operationer på tonsiller och adenoid” (Operations on tonsils and adenoid). A better name in the common version could be like the title of this case, Tonsil and adenoid procedures.

We agree that we should analyze whether cases with 03S11 should be grouped to another DRG but we appreciate if Finland does that analysis. We have already too many analyses to be able to finish them before the expert network spring meeting.

MDC03-02-2012.jpg (59 KB) Anonymous, 2013-11-19 13:47

MDC03-02-2012_2.jpg (8.88 KB) Anonymous, 2013-11-19 13:48

TECHNICAL_CHANGES_SWE_2012-02-17.xls (76.5 KB) Anonymous, 2013-11-22 13:09


#1 Updated by Anonymous over 5 years ago

#2 Updated by Martti Virtanen almost 5 years ago

  • Status changed from Accepted to Re-activated

2014-11-18 Martti Virtanen/Kristiina Kahur
In the beginning of November 2014 Estonian Health Insurance Fund (EHIF) discovered a mistake in EST2014PR0F version. Some cases that were expected to be assinged to DRG 060O were assinged to DRG 470O. The reason was that in the logic-table: the rule 103D12010103D12010 for DRG 060O had secproc1 '+' which it should not have had.
The problem was in NordDRG Common logic and thus affected also the common version and the Latvian version. In addition the same error was in Icelandic version (where it had not been noted). In Norwegian version the same error existed but the the rule without secproc1 '+' for DRG 060O was also retained and thus the DRG assignment was correct.
As stated by Mats Fernström the rules with secproc1 '+' are unnecessary after the changes in this case and the '+' must be removed. The the second logic row for DRG 060O with proc1 '03S03'but without secproc1 '+' must be inactivated in all versions.
In the Finnish and Swedish versions the change has been correctly implemented.
The corrections will be done for 2015 versions

#3 Updated by Martti Virtanen over 4 years ago

2014-11-25 Martti Virtanen
Daina Kanepaja, Senior expert of Inpatient Services Division, Departament of Health Service from Latvia noted the same error. In addition her report revealed to me that the english name of the DRG 060X is not corrected
060X 'Tonsillectomy &/or adenoidectomy only, age 0-17, should be 'Operations on tonsils or adenois' like it is for 060O. The age groups are no more active and thus the age limits have to be left out. The name should be as proposed by Mats Fernström.
Name correction does not necessitate production of new version of grouper.

#4 Updated by Anonymous over 4 years ago

  • Priority changed from Normal to Error correction

#5 Updated by Anonymous over 4 years ago

  • Status changed from Re-activated to Further active

#6 Updated by Anonymous almost 3 years ago

  • Status changed from Further active to Accepted

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