Case #377

Gallbladder codes complicate each other

Added by Anonymous almost 5 years ago. Updated almost 2 years ago.

Status:AcceptedStart date:2015-01-27
Priority:MinorSpent time:-
Assignee:Ralph Dahlgren
Category:-
Target version:Expert Group 2017
Initiator:Sweden Target year:2018
Case type:Minor Owner / responsible:National organisations
MDC:MDC07 Old forum status:
Target Grouper:SWE

Description

Description:

National ID: CPK ID C414
Initiated: 2012-02-16
Initiator: Ralph Dahlgren, The Swedish National Board of Health and Welfare

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Problem
From the Swedish health care system suggestions have come up that codes that concerns K80.- and K82.- are about the same thing but they complicate each other. This have now made the clinics to use double coding to get extra reimbursement.

Analysis
NPK Sweden – 2014-12-07, NCC 2015-02-10
The involved codes are shown below:

K800 Calculus of gallbladder with acute cholecystitis
K801 Calculus of gallbladder with other cholecystitis
K803 Calculus of bile duct with cholangitis
K804 Calculus of bile duct with cholecystitis
K808 Other cholelithiasis
K810 Acute cholecystitis
K820 Obstruction of gallbladder
K821 Hydrops of gallbladder
K822 Perforation of gallbladder
K823 Fistula of gallbladder
K830 Cholangitis
K830A Sclerosing cholangitis
K830X Cholangitis NOS
and for 07c16
K8320 Perforation of bile duct
K8330 Fistula of bile duct

The last two are Swedish added subcodes to ICD-10.

The codes belong to complication categories 07C15 'Cholelithiasis', 07C17 'Obstruction, perforation of fistula of gallbladder', 07C18 'Acute cholecystitis', 07C19 'Cholangitis' and 07C21 'Choledocholithiasis'.
Additional complication categories in the same problem area is 07C16 'Perforation of bile duct'.

Currently som combinations of these codes result in assignment to complicated/very complicated DRG although the added extra code is actually logically included in the first code.

For example a case with K8000 'Calculus of gallbladder with acute cholecystitis' is assigned alone to DRG 208X 'Disorders of biliary tract w/o cc'(G40E Gallvägssjukdomar, ej komplicerat). If secondary dx K8100 'Acute cholecystitis' is added the case will be assigned to DRG 207M 'Disorders of biliary tract w mcc' according to CC logic and 207X 'Disorders of biliary tract w cc' accordign to COM-logic. In SWE version the DRG is G40A Gallvägssjukdomar, mycket komplicerat.
This is an obvious error.

The problem is much broader than detected by Sweden. The attached matrix of the complication categories and exclusions of the gall system indicates all possibilities. It includes all ICD-codes starting with 'K8'. The pure pancreas codes that are not associated with the current problem are marked by yellow. The current complication categories are listed and all current exclusions are marked wiht 'X'. The Swedish proposal is marked with red 'S'.

It is obvious that the Swedish list is imcomplete. The example abouve could be coded with K8050 'Calculus of bile duct without cholangitis or cholecystitis' + K8100 'Acute cholecystitis' which would still result in MCC DRG. However, if the patient has acute cholecystitis, it is obviously wrong to use K8050 and the grouping is as wrong as in the original example.

Second example with K8310 'Obstruction of bile duct' with secondary diagnosis K8200 'Obstruction of gallbladder' will also result in assignment to CC-DRG although the the combined use of the dx's is highly questionable.
Suggestion 1:

Add a number of exclusions to the complication categories. In addition to the Swedish proposal a large number needs to be added. The matrix is checked only for 07C17 and even there some questions remain.

Suggestion 2:
All complication categories at issue are combined to 07C15/07G15. The exclusions are those of current 07C15 with the addition of K8700 that is obviously missing by error from 07C15.

DRG change
Some cases that now are grouped to complicated DRG will group to basic level a DRG.

Technical change

See matrix of properties

C414 Technical changes Decision NPK C414.xls (49.5 KB) Anonymous, 2015-02-09 09:39

C414 to Forum.docx (16.8 KB) Anonymous, 2015-02-09 09:39

Technical changes NPK C414.xls - Proposal from SWE (50 KB) Martti Virtanen, 2015-02-10 11:30

Gallbladder COMP and KOMPLEX.xlsx - Matrix of properties (10.1 KB) Martti Virtanen, 2015-02-10 11:30

Gallbladder_COMP_KOMPLEX.jpg (260 KB) Martti Virtanen, 2015-03-05 13:04

Appendix #377_SWE2017.xlsx (182 KB) Mats Fernström, 2017-02-22 09:37

Suggestion #377_SWE2017.xlsx (22 KB) Mats Fernström, 2017-02-22 09:37

TC #377_C414.xlsx (26 KB) Mats Fernström, 2017-03-28 17:11

Technical changes case #377.xlsx (42.3 KB) Martti Virtanen, 2017-05-11 13:20

History

#1 Updated by Anonymous almost 5 years ago

#2 Updated by Martti Virtanen almost 5 years ago

  • Description updated (diff)

#3 Updated by Martti Virtanen almost 5 years ago

  • Description updated (diff)

#4 Updated by Martti Virtanen almost 5 years ago

2015-02-10 Martti Virtanen
I have modified the proposal in the basic text.
See the second proposal.

#5 Updated by Martti Virtanen over 4 years ago

  • Description updated (diff)

#6 Updated by Martti Virtanen over 4 years ago

  • File Gallbladder_COMP&KOMPLEX.jpg added
  • Description updated (diff)

#8 Updated by Martti Virtanen over 4 years ago

  • File deleted (Gallbladder_COMP&KOMPLEX.jpg)

#9 Updated by Martti Virtanen over 4 years ago

  • Description updated (diff)

#10 Updated by Martti Virtanen over 4 years ago

2015-03-13 Expert group/MV
The matter prooved to be quite complex and the practical effect is small. The case was postponed for analysis performed by Sweden

#11 Updated by Anonymous almost 4 years ago

  • Target version changed from Minor-Proposals-for-2016 to Expert Group 2015

#12 Updated by Martti Virtanen over 3 years ago

  • Status changed from Active to Further active

2016-03-15 Expert group (MV)
No analysis has been performed but the case was considered to have significance and was therefore not closed.

#13 Updated by Mats Fernström over 2 years ago

Comments
Mats Fernström, NPK, Sweden, 2017-02-14
NPK ID C414
This case has been postponed twice so the problem should be solved at the spring meeting 2017. After spending several days on this very complex case I will have a nervous breakdown if anyone suggests further analyses.
I started by updating Martti´s matrix with the diagnosis codes beginning with K86, Swedish sub codes to K830 and some missing complication categories (07C06, 07C07 and 07C11). The updated new matrix is in the sheet “New MATRIX” in the file Appendix #377_SWE2017.xlsx. In the matrix, one sees clearly illogical differences regarding the CC properties of the diagnosis codes beginning with K8. These differences are commented in the sheet “Notes to New MATRIX”, where also the needs for the different analyses are mentioned. All calculations for the analyses are in the sheet “Calculations” (see "Read me" before using that sheet). The calculations and medical judgements concerning CC properties of the diagnosis codes beginning with K8 are summarized in the sheet “Summary”. In summary, the proposed changes to be done in the table Dg1 are:
K8000 ‘Calculus of gallbladder with acute cholecystitis’; COMPL 07C15 ‘Cholelithiasis’ is changed to 07G18 'Acute cholecystitis- major CC'.
K8030 ‘Calculus of bile duct with cholangitis’; COMPL 07C21 ‘Choledocholithiasis’ is changed to 07C19 'Cholangitis'.
K8040 ‘Calculus of bile duct with cholecystitis’; COMPL 07C21 ‘Choledocholithiasis’ is changed to 07G18 'Acute cholecystitis- major CC'.
K8080 ‘Other cholelithiasis’; COMPL 07I15 is removed.
K8110 ‘Chronic cholecystitis’; COMPL 07C15 with the new text 'Chronic cholecystitis' is added.
K8200 ‘Obstruction of gallbladder’; COMPL 07C17 ‘Obstruction, perforation of fistula of gallbladder’ is removed.
K8210 ‘Hydrops of gallbladder’; COMPL 07C17 ‘Obstruction, perforation of fistula of gallbladder’ is removed.
K8220 ‘Perforation of gallbladder’; COMPL 07C17 ‘Obstruction, perforation of fistula of gallbladder’ is changed to 07G16 'Perforation of bile duct- major CC'.
K8330 ‘Fistula of bile duct’; COMPL 07C16 'Perforation of bile duct’ is changed to 07C17 ‘Obstruction, perforation of fistula of gallbladder’.
K8600 ‘Alcohol-induced chronic pancreatitis’; COMPL 07C07 'Chronic panreatitis' is added.
K8630 ‘Pseudocyst of pancreas’; COMPL 07C07 'Chronic panreatitis’ is changed to 07G07 'Chronic panreatitis- major CC'.
All these changes are motivated in the sheet “Summary” in the file Appendix #377_SWE2017.xlsx and they are visualized in the sheet “Final MATRIX” where all suggested changes are marked with blue characters.
As a result of these changes, the complication categories 07C21 ‘Choledocholithiasis’ and 07I15 ‘Cholelithiasis’ are no longer used and they disappear from the system, at least in the Swedish version. The diagnosis property 07X01 that was meant to activate 07I15 is not used either so that property can be deleted from the diagnoses in the table Dg1 and from the table Dgprop.

The next step for the analysis in this case was to judge the exclusion lists for the remaining complication categories. Cost data are of minor help for this matter, because then we have to calculate on a large number of combinations of diagnosis codes and then there will be a small number of cases per combination and then cost data are less reliable. Therefore a medical judgement is important and the principles in my judgements have been that 1/ similar conditions must not complicate each other and 2/ a less “expensive” condition must not complicate a more serious condition. The following minor changes are suggested.
Exclusions for 07C07/07G07 ‘Chronic pancreatitis’: Since K860 ‘Alcohol-induced chronic pancreatitis’ is added to this complication category, it is of course also added to this exclusion list. Chronic pancreatitis is less serious than acute and the sparse cost data does not support that chronic pancreatitis should complicate acute pancreatitis. Thus, all codes for acute pancreatitis are added to this exclusion list.
Exclusions for 07C15/07G15 with the new text 'Chronic cholecystitis': Chronic cholecystitis is a rather undramatic condition and the most common reason for cholecystectomy. It should not be able to complicate any of the diagnoses beginning with K8. Thus, all codes beginning with K86, code K870 and code K871 are added to this exclusion list.
Exclusions for 07C16/07G16 ‘Perforation of bile duct’: Since K822 ‘Perforation of gallbladder’ is added to this complication category, it is of course also added to this exclusion list.
Exclusions for 07C17/07G17 ‘Obstruction, perforation of fistula of gallbladder’: Since K833 ‘Fistula of bile duct’ is added to this complication category, it is of course also added to this exclusion list.
Exclusions for 07C18/07G18 ‘Acute cholecystitis’: Since K800 ‘Calculus of gallbladder with acute cholecystitis’ and K804 ‘Calculus of bile duct with cholecystitis’ are added to this complication category, they are of course also added to this exclusion list. Acute cholecystitis may complicate chronic cholecystitis so K811 ‘Chronic cholecystitis’ is removed from this exclusion list.
Exclusions for 07C19/07G19 ‘Cholangitis’: Since K803 ‘Calculus of bile duct with cholangitis’ is added to this complication category, it is of course also added to this exclusion list.
The suggested exclusions above can be seen in the sheet “Final MATRIX” in the file Appendix #377_SWE2017.xlsx where all suggested changes are marked with blue characters.
All technical changes are specified in the file Suggestion #377_SWE2017.xlsx.

#14 Updated by Mats Fernström over 2 years ago

Mats Fernström, NPK, Sweden 2017-03-28
If it can be of any help, I attach technical changes (TC #377_C414.xlsx) according to the new NCC template including an update of test data.

#15 Updated by Martti Virtanen over 2 years ago

2017-03-13 Expert group
Accepted according to the suggested changes by Mats Fernström.
See the annex Appendix #377_SWE2017.xlsx (182 KB) and Suggestion #377_SWE2017.xlsx (22 KB).

#16 Updated by Martti Virtanen over 2 years ago

2017-05-11 Martti Virtanen
Technical changes for NordDRG Com
The Compl. Excl table is inluded in #495, to check that there are no discrepancies. These changes are valid.
A few minor changes compared with the document from Sweden in addition to the ICD+ based definitions.

#17 Updated by Martti Virtanen almost 2 years ago

  • Status changed from Further active to Accepted

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