Case #408

Respiratory failure in newborns

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

Status:AcceptedStart date:2015-02-26
Priority:MinorSpent time:-
Assignee:Kristin Dahlen
Target version:Expert Group 2015
Initiator:Norway Target year:2016
MDC:MDC15 Owner / responsible:National organisations
Target Grouper:NOR Old forum status:


National ID: HD-0109
Initiated: 2015-02-25
Initiator: Norwegian Directorate of Health
Responsible at National organization: Kristin Dahlen
Sent to NordDRG Forum: 2015-02-25
We observe some inconsistency in the DRG logic for newborns with respiratory problems, as can be seen in the table.

Babies between 8 and 29 days old coded with P2850 'Respiratory failure of newborn' without anh procedures code are assigned to DRG 385B/Q10N 'Follow-up care of neonatal problems or delayed neonatal problem, birth weight 1000 g or more'.

If procedure WAA728/GXAV10 'Continuous positive airway pressure therapy (CPAP)' is perorformed, the case will assingned to DRG 390/Q55N 'Neonate, birthweight 2500 g or more, with other significant problem'.

This does not make sense, and can lead to a problem with reporting WAA728/GXAV10.

WAA728/GXAV10 has the procedure property 15S02 'Neonatal intensive care procedure'.

The problem seems to be the rule 015D8011. Be aware that the table presented here only shows part of the logic.

Norwegian directorate of health
No economical analysis available.

Norwegian directorate of health – 2015-02-25

We suggest to move the rule 015D8011 below rule 015D8221 (DRG 388B). Accordingly we suggest to remove the secproc -15S02 from rule 015D8011.

The rule 015D80109 can then be deleted.

HD-0109-1.jpg (47.1 KB) Anonymous, 2015-02-26 16:01

HD-0109-2.jpg (116 KB) Anonymous, 2015-02-26 16:03

TC #408_C604.xlsx (16.2 KB) Mats Fernström, 2017-03-28 17:23

Technical changes case #408.xlsx (44.3 KB) Martti Virtanen, 2017-05-19 15:05


#1 Updated by Martti Virtanen over 6 years ago

  • Description updated (diff)

2015-03-05 Martti Virtanen
The basic idea in the neonatal chapter is that neonatal care is either care that started during the first week of life or care that started after the first week of life but during first 4 weeks of life with some neonatal intensive care interventions (15S02) performed. The interventions are not expensive but they indicate that the case is actually neonatal care. However, things may change and it is possibly usefull to reanalyze the situation.

Further analysis
Thus the point is to analyze the cost and frequency of neonates admitted to hospital after first week of life before 29 days of age. These data should be compared with neonates admitted during first week of life and the analyze the effect of 15S02.

Here as with tracheostomy the cost of the intervention affecting DRG-assignment has no significance. The interventions are an indicator not the cost driver.

#2 Updated by Ralph Dahlgren over 6 years ago

Sweden agree with Martti that this case needs further analysis.

#3 Updated by Martti Virtanen over 6 years ago

  • Status changed from Active to Further active
  • MDC MDC15 added

2015-03-03 Expert group/MV
The case needs proper economic analysis and is postponed for next year.
The technical change needs to be reformulated after the analysis.

#4 Updated by Anonymous over 5 years ago

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

#5 Updated by Martti Virtanen over 5 years ago

2016-03-15 Expert group (MV)
No further analysis had been done for the case. It was considered to be significant and was not closed.

#6 Updated by Kristin Dahlen about 5 years ago

Kristin Dahlen 2016-06-24
Further to these case we would like to add a new issue regarding the use of GXAV10. If a 17 days old baby arrives at hospital with a pneumonia and an acute respiratory failure (main condition J210 and other conditions J180 and J960), the case will lead to DRG 91A 'Lungebetennelse & pleuritt 0-17 år m/bk'. If procedure GXAV10 'Continuous positive airway pressure therapy' is performed, the DRG will be DRG 390/Q55N 'Neonate, birthweight 2500 g or more, with other significant problem. At least in Norway the last mentioned DRG group do have much lower cost weight than 91A.

We are putting this comment in as well as we might discuss the principle regarding MDC 15 or other MDC in this case or even in more common. In this example, and in the case described above it is the properties for GXAV10 which causes the change in DRG.

#7 Updated by Mats Fernström over 4 years ago

Mats Fernström, NPK, Sweden 2017-03-01
We have the same problem in Sweden. Adding any of the procedure codes with 15S02 (Neonatal intensive care procedure) will move the case from the more expensive DRG 385B/Q10N to the less expensive DRG 390/Q55N, even though the costs don’t differ that much as in Norway. We agree that this is no good.
My first reflection is: Why is the group for patients without intensive care procedures (DRG 385B/Q10N) more expensive than the group for patients with intensive care procedures (DRG 390/Q55N)? Do we have creative coding? Maybe the patients in DRG 385B/Q10N have had intensive care, resulting in higher KPP, but the procedure codes are omitted to prevent from grouping to a DRG with lesser weight? Well, we don’t know, but we should not have incentives for poor coding in NordDRG.
We have analyzed the suggestion which was to remove the secproc -15S02 from rule 015D8011 (015D801110 in SWE) leading to DRG 385B/Q10N and to transfer that rule to below rule 015D8221 (015D822100 in SWE) leading to DRG 388B/Q30N. It was also suggested that rule 015D80109 (015D801010 in SWE) is deleted.
An effect of this change will be that all patients 8-28 days old with a principal diagnosis in MDC 15 and a procedure with 15S02 that now are grouped to DRG 390/Q55N according to the nine rules with ORD 015D82709-015D82717 (015D827090-015D827170 in SWE) instead are grouped to DRG 385B/Q10N. Also patients 8-28 days old with a principal diagnosis in MDC 15 and a diagnosis with 15X91 that now are grouped to DRG 391/Q60N (Normal newborn) according to the rule 015D828000 will instead go to DRG 385B/Q10N.
All these theoretical movements of patients may look impressive but there is not much happening in reality. We regrouped our national Patient Register (PAR) and our KPP database for 2014 after doing the proposed technical changes. In PAR, only 6 cases out of totally 10 600 went from DRG Q55N to DRG Q10N. In KPP, 4 cases out of totally 5 400 went from DRG Q55N to DRG Q10N. One patient was an outlier (cost = 372 618 SEK). The average cost for the other three was 40 700 SEK, which suits better in DRG Q55N than in DRG Q10N but cost data is not reliable with that small number of observations.
In summary – the suggested changes will reduce incentives for poor coding and very few cases will be affected so we think it is OK to implement these changes and then this case can be closed.
The new problem added by Kristin 2016-06-24 will not be solved by the suggested changes. That problem is a bigger issue, it is about which patients that shall be grouped to MDC 15 or not, and it should be a separate case on the Forum. The grouping logic for neonatal patients was developed 2001 and perhaps it is time for a revision since we now have much more and better cost data than 15 years ago.

#8 Updated by Martti Virtanen over 4 years ago

2017-03-09 Martti Virtanen
The comment from Norway takes up an importan detail, not directly related to this case.
In the group of patients between 8-28 days the detection of neonatal condition is based on 'neonatal intensive care intervention'. 'Continuous positive airway pressure therapy' belongs to this group.

It is ovbiously demoralizing that coding of an intervention decreases the reimbursement, but this may be quite difficult to avoid. Shortening the period that is ptotential regarded as neonatal might help.

#9 Updated by Martti Virtanen over 4 years ago

  • Description updated (diff)

#10 Updated by Mats Fernström over 4 years ago

Mats Fernström, NPK, Sweden 2017-03-28
If it can be of any help, I attach technical changes (TC #408_C604.xlsx) according to the new NCC template. There are already a lot of test cases that were grouped according to the rule with ORD 015D801110 and several of them will now be grouped according the rule with ORD 015D822200. Therefore I see no reason to construct new test cases.

#11 Updated by Martti Virtanen over 4 years ago

2017-03-13 Expert group
Accepted as originally proposed.
The rules 015D801110 and 015D8011101 (id's) will be moved after the rules for DRG 388B (last with id 015D8221001). The secproc -15S02 is removed.
Last comment from Norway may necessiate a new case? Look last comment from Martti (2017-03-09).
Technical changes are necessary.
Denmark has promised to give a presentation about neonatal grouping in autumn meeting/spring meeting 2018?

#12 Updated by Martti Virtanen over 4 years ago

2017-05-19 Martti Virtanen
Technical changes for combined NordDRG Com

#13 Updated by Martti Virtanen over 3 years ago

  • Status changed from Further active to Accepted

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