Case #392

Pancreas interventions in cases with problems of unspecified digestive organs

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

Status:AcceptedStart date:2015-02-11
Priority:MinorSpent time:-
Assignee:Ralph Dahlgren
Category:-
Target version:Expert Group 2015
Initiator:Sweden Target year:2016
Case type:Minor Owner / responsible:National organisations
MDC:GEN Old forum status:
Target Grouper:SWE

Description

National ID: NPK C473
Initiated: 2015-01-03
Initiator: Ralph Dahlgren The Swedish National Board of Health and Welfare
Responsible at National organization: Ralph Dahlgren The Swedish National Board of Health and Welfare
Sent to NordDRG Forum: 2015-02-05
Status: ACTITEM - Active item
----------------------------------------------------------------------------------------------------------------
Problem
A problem of grouping in the DRG system has been brought to our attention from the clinicians.
Primarily concern is the D3770 'Neoplasm of uncertain or unknown behavior of other digestive organs' (Tumör av osäker eller okänd natur i andra matsmältningsorgan) that includes according to ICD-10 tumors of anal canal, anal sphincter, anus UNS, esophagus, pancreas and intestine UNS). It belongs to MDC06 'Gastrointestinal problems'. It is the code used for unclear tumor of the pancreas. Typically it is associated with JLSC30 'Pancreatoduodenectomy' (Pankreasresektion) that has intervention properties for MDC 06, 07, 10, 14 and 21. This combination results in assignment to DRG F35E-C-A/170-171 'Other operations in the stomach and intestine, not complicated/complicated/very complicated' (Andra operationer i mage och tarm, ej komplicerat/komplicerat/mycket komplicerat).

If, instead, the principal dx is D3760 'Neoplasm of uncertain or unknown behaviour of liver, gallbladder and bile ducts', that belongs to MDC07 'Liver and pancreas problems', is used (together with the code JLSC30), the case is assigned to DRG G05E-C-A/192 'Pancreas, liver or bypass surgeries, not complicated/complicated/very complicated' (Pankreas-, lever- eller shuntoperationer, ej komplicerat/komplicerat/mycket komplicerat). This is truth for all MDC07 specific dx's (like D1360 'Benign neoplasm of pancreas' or C2500 'Malignant neoplasm of head of pancreas'.

Analysis
The Swedish National Board of Health and Welfare – 2015-01-03
This is a medical description problem, not a reimbursement problem.

Suggestion
The Swedish National Board of Health and Welfare – 2015-01-03
Clinically the principle should be that a resection of Pancreas whatever reason should be grouped to G05E-C-A/192.

Sweden wants this to be introduced in the Swedish NordDRG 2016

Technical change
A new row in DRGlogic is created just above each of the existing DRG F35/170-171 rules.
The rows will have new ord, the DRG will be G05, ICD +, MDC will be empty.
A new PDGPROP is created, 07P18 ‘Possible pancreatic disease’.
PROCPRO will be the same as for DRG G05. COMPL will be “empty “or contain the number “1” or “2”.
The rest will be the same.
The ICD-codes that will have the new PDGPROP 07P18 is:
D377 Tumör av osäker eller okänd natur i andra matsmältningsorgan
D377A Tumör av patologiskt osäker natur i andra matsmältningsorgan
D377B Tumör av kliniskt okänd natur i andra matsmältningsorgan
D017 Cancer in situ i andra specificerade matsmältningsorgan
For technical changes see Excel file ”Decision C473 Resection of Pancreas with ICD-code D37.7”

DRG change
Some patient cases will be grouped from DRG F35E, C, A Andra operationer i mage och tarm, ej komplicerat/komplicerat/mycket komplicerat (Other operations in the stomach and intestine, not complicated/complicated/very complicated. Former DRG 170) to DRG G05E, C, A Pankreas-, lever- eller shuntoperationer, ej komplicerat/komplicerat/mycket komplicerat (Pancreas, liver or bypass surgeries, not complicated/complicated/very complicated, former DRG 191B).

Introduction: NordDRG [SWE] [2016]

C473 Decision C473 Resection of Pancreas with ICD-code D377.xlsx (16.9 KB) Anonymous, 2015-02-11 12:21

C473 Resection of Pancreas with ICD-code D37 7 to Forum.docx (18 KB) Anonymous, 2015-02-11 12:21

Decision C473 Resection of Pancreas with ICD-code D377.xlsx (17 KB) Ralph Dahlgren, 2016-02-04 15:58

Decision C473 revised.xlsx (17.2 KB) Mats Fernström, 2016-04-14 16:28

History

#1 Updated by Martti Virtanen over 4 years ago

  • Subject changed from Resection of Pancreas with ICD-code D37.7 Tumör av osäker eller okänd natur i andra matsmältningsorgan (Neoplasm of uncertain or unknown behavior of other digestive organs) to Pancreas interventions in cases with problems of unspecified digestive organs
  • Description updated (diff)

#2 Updated by Martti Virtanen over 4 years ago

  • Description updated (diff)

2015-02-25 Martti Virtanen

The problem has two sides. There are a number of dx that belont to MDC 6 but are obviously potentially pancratic problems.
This is on ICD+ a list of those dx:

C2690 Malignant neoplasm of ill-defined sites within the digestive system
C7620 Malignant neoplasm of abdomen
C7880 Secondary malignant neoplasm of other and unspecified digestive organs
D0170 Carcinoma in situ of other specified digestive organs
D0190 Carcinoma in situ of digestive organ, unspecified
D1390 Benign neoplasm of ill-defined sites within the digestive system
D1750 Benign lipomatous neoplasm of intra-abdominal organs
D3770 Neoplasm of uncertain or unknown behaviour of other digestive organs
D3790 Neoplasm of uncertain or unknown behaviour of digestive organ, unspecified
K9180 Other postprocedural disorders of digestive system, not elsewhere classified
K9190 Postprocedural disorder of digestive system, unspecified
K9280 Other specified diseases of digestive system
K9290 Disease of digestive system, unspecified
K9380 Disorders of other specified digestive organs in diseases classified elsewhere
O9960 Diseases of the digestive system complicating pregnancy, childbirth and the puerperium
Q4080 Other specified congenital malformations of upper alimentary tract
Q4090 Congenital malformation of upper alimentary tract, unspecified
R1010 Pain localized to upper abdomen
R1040 Other and unspecified abdominal pain
R9330 Abnormal findings on diagnostic imaging of other parts of digestive tract
T1880 Foreign body in other and multiple parts of alimentary tract
T1890 Foreign body in alimentary tract, part unspecified
T2870 Corrosion of other parts of alimentary tract
T9150 Sequelae of injury of intra-abdominal and pelvic organs

Some of these dx are rarely if ever associated with interventions while others quite typically may have that connection.

Of the pancreatic interventions (NCSP+ codes starting with 'JL')a proportion (round 1/3) have both a property for MDC 6 and for MDC 7. When these interventions are used with the dx above, the cases will be assigned to gastrointestinal DRG's.

To some extent this problem extends to liver and bile system interventions, at least because liver interventions may be performed because of pancreatic problems. Most of ICD codes at issue are specific for liver and there is no need for this kind of cross properties.
We have already dealt with O9960 'Diseases of the digestive system complicating pregnancy, childbirth and the puerperium' in Case #262 but what is obvious, O9960 should also be used for any pancreatic problem during pregnancy, which was not taken in account on that case.

Of the liver interventions only most of diagnostic interventions (JJSA group of NCSP+) and all liver resections (JJSB group of NCSP+) and JKSC50 'Excision of papilla of Vater and anastomosis of bile duct to duodenum or jejunum', JKSE00 'Transduodenal papillotomy' and JKSE02 'Transduodenal endoscopic incision of common bile duct orifice' have properties for surgical interventions both for gastrointestinal system (06Sxx) and liver and pancreas (07Sxx). The need for diagnostic interventions for both groups is obvious, the others are questionable.

Alternative suggestion
The property 07P14 is renamed to 'Potential liver or pancreas problem'
It is given to all dx listed above.
All 06Sxx properties are removed from all pancreatic interventions (JL-group in NCSP+)
Possibly also removal of 06Sxx properties from liver interventions except JJSA group.
To both inpatient and outpatient rules for DRG G05x/192x a second rule is created with 07P14 but without MDC 07 (1+3 rules in NordDRG Swe).

All cases with the listed dx and pancreas or liver interventions will be assigned to MDC 07 DRG's. Cases with liver or bile interventions will be assigned to correct DRG's.
Cases without pancreas or liver related dx with these interventions will be assigned to DRG 468-477/Z50x-Z60N

Further analysis
How many cases would change groups? Would there be any new cases in 468-477?

#3 Updated by Ralph Dahlgren over 4 years ago

Martti alternative is so extensive that this must be investigated separately. We wish that our proposal is implemented for 2016. The remaining investigation may be made to NordDRG 2017

#4 Updated by Martti Virtanen over 4 years ago

2015-03-13 Expert group/MV
The case proved to be too complicated to be decided now. It was postpone to next year. Sweden (and at least Finland) shall do further analysis.

#5 Updated by Martti Virtanen over 4 years ago

  • Status changed from Active to Further active

#6 Updated by Anonymous almost 4 years ago

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

#7 Updated by Ralph Dahlgren almost 4 years ago

The Swedish National Board of Health and Welfare 2016-02-04

Sweden has now continued with an investigation concerning this case. This included grouping before and after changing the Swedish definition tables according to Marttis suggestion. As we knew beforehand these changes will not concern many incare and out patients. But it turns out that if we accept Marttis suggestion we have to accept that almost around 35% more incare patients will be grouped differently.
Sweden wants our first suggestion to be implemented to the Swedish DRGlogic for 2017.
The technical changes are in the included file “Decision C473 Resection of Pancreas with ICD-code D377”.

#8 Updated by Martti Virtanen over 3 years ago

2016-03-15 Expert group (MV)
As proposed by SWE the proposal was reduced to the original proposal.

#9 Updated by Martti Virtanen over 3 years ago

2016-04-14 NordCase - MV
The technical changes proposed by SWE have a severe problem.
The basic case that induced the discussion would still not be assigned to MDC 7 but to MDC 6 based on rules 406D071001, 406D071003, 406D071005 or 406D071006. The principal dx D3770 will still belong to MDC 6 and the intervention JLSC30 have the properti 06S10. Adding pdgpro 07P18 will not help. Only the interventions (with 07S01) that do not have MDC 06 intervention properties (06Sxx) will be assigned by the new rules. This is at most 2/3 of the infervention.

What can we do?
We could remove the MDC 06 properties from (at least some) of the interventions. Some are probably not usable for MDC 06, and for those codes this would be OK.
We could move the rules to the middle of the MDC 06 rules (before the rules with 06S10?). This would move all cases with the dx at issue and 07S01 interventions to 192x (G05x) groups.

The second is less problematic to perform. However the a further analysis might be necessary.
Since the change is planned to be performed only in SWE (although the problem should be the same in all countries) SWE has to decide what should be done.

#10 Updated by Mats Fernström over 3 years ago

Mats Fernström, NPK, Sweden 2016-04-14
Thank you Martti. Of course you are right; our three suggested new rules will have no effect. Shame on us! We have to place them somewhere before the rules with 06S10 (leading to DRG F35). It is possible that the procedures with 07S01 can be combined with other gastrointestinal procedures so it is important to place the rules in the MDC 06 section with regard to the cost data (see table below).

DRG Mean SEK
F11E 197 612
F01E 132 745
F05E 88 800
F07E 73 077
F12E 66 083
F09E 59 145
F35E 48 048
G05E 154 120

These data indicate that the new rules should be placed before the rules for DRG F01 and we suggest the ORD values 406D011125, 406D011130 and 406D011135. Revised technical changes (Decision C473 revised.xlsx) are attached.

#11 Updated by Martti Virtanen over 2 years ago

  • Status changed from Further active to Accepted

2017-03-13 Expert group
The changes have been done already. Last change after spring meeting 2016.

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