Case 2008-GEN-05 Effect of ZT (or ZZ in original NCSP) coddes (Grafts, flaps and tissue expanders) on DRG assignment
|Target version:||Expert Group 2011|
|MDC:||GEN||Owner / responsible:|
|Target Grouper:||COMMON, DEN, EST, FIN, ICE, LAT, NOR, SWE||Old forum status:||CLOSITEM - Closed item|
Last updated: 2011-04-20
Status: CLOSITEM - Closed item
Error corrected by Nordic Centre
By: Nordic Centre
Expert Network 2008-03-06 - Postpone recommended
Steering Group 2008-03-31 - Recommendation accepted
Expert Network 2009-02-26 - Change recommended
Board 2009-03-20 - Recommendation accepted
Expert Network 2011-03-17 - Correction recommended
Board 2011-04-04 - Recommendation accepted
Then changes to NordDRG introduced in Hierarchic change in the NordDRG system for DRG 268 [[http://documents.norddrg.net/issues/242]] broke an earlier rule where the transplants where allowed to affect the DRG assignment without main code although these codes are only allowed to be used as additional codes. To be logical all procedure properties of the ZT (or ZZ in original NCSP) codes should be removed.
There are 82 such codes and all except one have OR=1 property. The only one without is ZTX00 ‘Free graft of mucosa’. These codes have altogether 255 properties i.e. in the mean 4 different properties each.
The Finnish data 2006 includes 1’996 classic cases and 584 short therapy cases.
Of the short therapy cases 418 are assigned to surgical DRG’s because of the OR=1 and procedure property of the ZT-codes. If the procedure property would be removed they would be assigned to DRG 477O because of the OR=1 property. If the OR=1 property would be removed 25 of these cases would be assigned to minor short therapy DRG’s because of OR=2 property of another code. 393 cases would be assigned to conservative short therapy DRG’s. Currently 50 cases are assigned to DRG 477O. In Swedish full version (SK-OP) however all 418 cases would be assigned to different short therapy intervention DRG’s independent of the OR property.
Of the classic cases 113 were assigned to surgical DRG’s because of OR=1 and procedure property of the ZT-codes. If the procedure property would be removed, these cases would be assigned to DRG 477. If OR=1 preperty would be removed these cases would be assigned to conservative classic DRG’s. Currently 26 cases are assigned to DRG 477.
The mean cost of the 418 short therapy cases was 392 € (V% 84.5%). The trimmed cost of DRG 477O (“prospective price”) of this group was in the Finnish 2006 data 1'038 €.
The mean cost of the 113 classic cases was 3’219 € (V% 147%). The trimmed cost of DRG 477 (“prospective price”) of this group was in the Finnish 2006 data 4'293 €.
Without any change the payment to the hospitals would with current “trimmed price” be in the mean 514 € for short therapy cases and 4'082 € for the classic cases if these groups are fully reimbursed.
It would be logical to remove the procedure properties of all ZT-codes but retain the OR=1 property. This would result in assignment to DRG 477O or 477 which would indicate the obvious error in coding. Removing OR=1 property would result in assignmet to conservative DRG’s. There would be no indication of the false coding and the reimbursement would be dependent on secondary factors.
Expert Network 2008-03-06
The meeting proposed to postpone the case for further investigation and analysis by Sweden and the Nordic Centre.
CPK, Sweden 2009-02-19
The effects of the suggestion are difficult to grasp and it seems to be a complicated way to solve a small problem and we certainly don’t want more patients in DRG 477 than absolutely necessary. Besides, there will be no pressure on the DRG user to register the correct codes if the payment is still rather good (or even better).
An easier and better way to counteract an improper use of the procedure codes in chapter Z is to construct a rule leading to DRG 470 if the Z-codes are registered alone. Then the DRG user has to correct the primary coding to get paid.
Expert Network 2009-02-26
The meeting recommended the proposal to construct a rule leading to DRG 470 if the Z-codes are registered alone.
All NCSP-codes starting with Z are given property 00S99 ‘Unspecified of impossible procedure’.
The rule 000D00002 for DRG 470 is modified so that OR is given value ‘S’.
The affected codes for all national versions are listed in the attached table (NCSP+Z-codes.xls).
Cases with only NCSP Z-codes with OR=1 property and Z-codes combined with anesthesia code result in assignment to DRG 470. Procedure WZ998 ‘Other impossible or unspecifed procedure’ (NCPS+) and all national codes mapped to it have OR=1 and 00S99 property and are therefore still assigned to DRG 470.
Martti Virtanen, 2010–08–26
The model has caused grouping of correctly coded cases to DRG 470 which is obviously unacceptable. For example a skin intervention code QxES99 ‘Other excision or repair of skin of …’ combined with ZTXA50 ‘Full thickness skin craft’ results in DRG 470 (or 470O). The problem does not exist if neither the main intervention nor the Z-code is an OR-code (OR=1). In the case of skin crafts the Z-codes have property OR=1. However removing the OR property from these codes will not solve the problem since adding anesthesia code would recreate it. Also other interventions with anesthesia can currently cause this problem.
To avoid this we need to restrict effect of the created coding error rule. After number of discussions it was agreed that the problem is most logically solved by excluding cases with anesthesia from this rule. Thus if the procedure is done with anesthesia the Z-codes may be added to any code. In the case of the skin crafts, this means that the anesthesia, that is obviously needed for the operation, has to be coded. This means that following coding in the original example:
D03.6 ‘Melanoma in situ of upper limb including shoulder’
QCES99 ‘Other excision or repair of skin of upper limb’
ZTXA50 ‘Full thickness skin craft’
results still in DRG 470
Adding code for “general” anesthesia, for example:
WAA202 ‘Supraclavicular plexus blockade’
results in DRG 266 ‘Skin graft &/or debrid except for skin ulcer or cellulitis w/o cc’ or 266O if short stay, which is correct.
To rule 000D00002 is added dgprop1 -00X10.
Combination of intervention Z-code (code with 00S99 property) with non-or procedure (without OR=1) is always allowed with anesthesia. Anesthesia is obligatory only for skin graft Z-codes that have OR=1 property. Without anesthesia codes the cases are still assigned to DRG 470. Minor intervention codes with Z-codes are ignored without anesthesia.
Expert Network 2011-03-17
The meeting recommended acceptance of the correction.
The case will be closed.
Martti Virtanen, 2013–03–22
A Finnish question revealed that the last phase of this case is missing - probably as a result of technical problems.
The use of anesthesia property still left the system with a number of correctly coded cases assigned to DRG 470. The basic idea is, that an additional code cannot be used without telling what is the intervention that was performed. This is not anesthesia but any other code for the intervention at issue.
For NordDRG 2012 it was therefore decided, that all codes that do not have property 00S99 shall have property 00X99, which is crated automatically during in the process of creating the definition tables.
It is important to note, that the NCSP+ mapping no reflect our view, which are the independent intervention codes and which are the additional codes that cannot be used independently (Z-codes in NCSP+). The structure of the national intervention classifications is not always correct in this respect.
A new property 00X99 'Intervention code valid for single use - property generated automatically'. However in NDMS no code will have this property, it will be generated in the process of creating the definition tables for the grouper programs.
All intervention codes that do not have 00S99 property will have property 00X99.
In the rule 000D00002 dgprop1 is changed to -00X99.
Combination of intervention Z-code (code with 00S99 property) will result in DRG 470 only if no other intervention code is registered.