Case #478

Extracorporeal VAD does not fit with cases in DRG 103

Added by Kristin Dahlen over 5 years ago. Updated almost 3 years ago.

Status:AcceptedStart date:2016-03-01
Priority:MinorSpent time:-
Assignee:Kristin Dahlen
Category:-
Target version:Expert Group 2016
Initiator:Norway Target year:2017
MDC:MDC05 Owner / responsible:
Target Grouper:COMMON Old forum status:

Description

Subject: Extracorporeal VAD does not fit with cases in DRG 103

Description:

National ID: HD-160
Initiated: 2016-02-29
Initiator: Norwegian Directorate of Health

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Problem
Extracorporeal VAD (FXL30) is, among other procedures, grouped to DRG 103 (Heart transplant and implantation of VAD). In this DRG we find the following procedures in the Norwegian version:

!Procedures in DRG103.jpg!

It is stated by Oslo University Hospital that implantation of extracorporeal VAD (FXL30) is not as expensive as a heart transplant in DRG 103. The extracorporeal VAD may be comparable with the IABP when it comes to resources used. The IABP (FXG00 Insertion and use of intra-aortal balloon pump) groups to DRG 110 (see case 271).

Analysis
Norwegian directorate of health – 2016-02-29

The table below shows that under half of the stays in the DRG is a heart transplant done by one hospital. The other cases are implantation of VADs, in some cases done by other hospitals.

!DRG 103 frequency.jpg!
(number of cases from the eight first month of 2015)

Problems regarding this and similar cases do have a long history. See Case 2011_MDC05-06, case #95 and case #271.

In 2011 Norway raised the same question, suggesting that VAD cases would not assign to DRG 103. At that time there was only one code for all sorts of VAD (FXL00). The meeting recommended rejecting the proposal based on KPP data from Sweden (Case 2011_mdc05_06). The problem was the procedure code FXL00 which contained three types of procedures, extra-, para-, and intra- thoric VAD. These three have a high variation of costs. As you will see from the table above we now have split the VAD into extracorporeal and intracorporeal (FXL30 and FXL60).

In case #95 Finnish costing data shows that cases with FXL00 (Insertion and use of extra-, para- or intracorporeal, VAD) were similar to cases with heart transplantation cases assigned to DRG 103. The result of the case 95 was: “A new DRG is created for cases with FX but no GBB interventions. Current DRG 483 would remain as it is. Cases with FXL00 and cases in MDC 15 are not affected”.

In case #271 the IABP cases were decided to move from DRG 483B till DRG 110 because of their relative lower expenses than other cases in DRG 483B. This is mentioned to emphasize the link between the costs of IABP and the extracorporeal VAD cases.

Suggestion
Norwegian Directorate of Health – 2016-02-29
We suggest that FXL30 is moved from DRG 103 to DRG 483B.

Suggestion Helsedir HD-160 Extracorporeal VAD.xlsx (46.5 KB) Kristin Dahlen, 2016-03-01 17:55

DRG 103 frequency.jpg (34.4 KB) Kristin Dahlen, 2016-03-01 18:01

Procedures in DRG103.jpg (111 KB) Kristin Dahlen, 2016-03-01 18:01

SWE FXL00 in KPP 2014.xlsx (10.5 KB) Mats Fernström, 2016-03-02 15:46

Appendix #478 SWE 2017.xlsx (10.2 KB) Mats Fernström, 2017-03-01 12:23

Technical changes case #478.xlsx (24.1 KB) Martti Virtanen, 2017-03-11 20:21

Technical changes case #478 new.xlsx (24.7 KB) Martti Virtanen, 2017-05-29 11:40


Related issues

Related to Case #95: Case 2013-GEN-01 ECLA/ECHLA (/ECMO) indicates high level ... Accepted
Related to Case #271: ECLA/ECHLA (/ECMO) indicates high level intensive care Accepted 2014-02-24

History

#1 Updated by Kristiina Kahur over 5 years ago

Finnish National DRG-Centre 2016-3-2

In Finnish version there is no separate procedure code for implementation of extracorporeal VAD. Code FXL00 is for coding insertion and use of extra-, para- or intracorporeal VAD.
It means that we can make the cost analysis only using the code FXL00 which is not exactly the same as Norwegian FXL30 (extracorporeal VAD).

Nevertheless, the results of the cost analysis (2013 five university hospital data) are as follows:
There have been 30 cases with code FXL00 and they have grouped to eight different DRGs. 16 out of 30 are in DRG 103 (Heart transplantation).
Mean cost of all 30 cases was ca 180 000 EUR (trimmed 149 000 EUR), mean cost in DRG was 103 242 000 EUR (trimmed 195 000 EUR).
The mean cost of DRG 103 (including all cases, not only FXL00 cases, # 32) was 213 000 EUR (trimmed 190 00 EUR).
The mean cost of DRG 483B (# 89) was 47 000 EUR (trimmed 43 000 EUR).

We can see remarkable difference between the DRGs 103 and 483B.

From economical point of view the cases with procedure code FXL30 should belong to DRG 103 rather than to DRG 483B. However, the results can be different if we could have separated only the cases with extracorporeal VAD.

Based on current cost analysis we are not in favor of suggested change.

#2 Updated by Mats Fernström over 5 years ago

Mats Fernström, NPK, Sweden, 2016-03-02
2015-01-01 the Swedish code FXL00 (Inläggande och användande av extra-, para- eller intrakorporeal VAD) was replaced by:
• FXL10 (Inläggande och användande av extrakorporeal VAD)
• FXL20 (Inläggande och användande av parakorporeal VAD)
• FXL30 (Inläggande och användande av intrakorporeal VAD).
Note the total different meaning of the Norwegian and Swedish codes FXL30!!!
But we don’t have cost data for the year 2015 yet. Therefor we cannot judge the suggestion and we want to postpone the case until next year. In our latest cost data (year 2014) the cases with FXL00 fit much better in DRG E01N (former DRG 103) than in DRG W02N (former DRG 483B). See the Excel file SWE FXL00 in KPP 2014.

#3 Updated by Martti Virtanen over 5 years ago

2016-03-09 Nordcase Martti Virtanen
I agree with Mats. If differentiation of intracorporeal and other VAD is necessary, we have to adjust the NCSP+ to this.

#4 Updated by Martti Virtanen over 5 years ago

  • Status changed from Active to Further active

2016-03-15 Expert group (MV)
The case was postponed for further analysis.

#5 Updated by Kristin Dahlen over 4 years ago

Norwegian Directorate of Health - Kristin Dahlen
2017-01-27

We do repeat our suggestion of moving the cases with FXL30 Innlegging av extrakorporal VAD to DRG 483B.
Please mark the earlier comment about FXL30 having a different meaning in the Swedish Version.

We also want to discuss further any new DRG solution for the intrakorporal and the parakorporal VADs.

#6 Updated by Kristiina Kahur over 4 years ago

Finnish National DRG-centre 2017-2-17

There has been no changes in Finland regarding the VAD codes, i.e. the code FXL00 embodies all three procedures and it is difficult to say which procedure exactly has been done in reality without checking the original medical documentation.
From cost point of view the cases with FXL00 belong to DRG 103 rather to 483B.
Based on that the Finnish position has not been changed compared to the one of 2016-3-2.

#7 Updated by Mats Fernström over 4 years ago

Mats Fernström, NPK, Sweden 2017-03-01
Kristin wrote “It is stated by Oslo University Hospital that implantation of extracorporeal VAD (FXL30) is not as expensive as a heart transplant in DRG 103”. This is probably true but the DRG system must take into account the cost of the entire care episode. Swedish cost data speak strongly against the proposed change (see Appendix #478 SWE 2017.xlsx) and we don’t want this change.

#8 Updated by Kristin Dahlen over 4 years ago

Due to a change in procedurecodes in this area for 2017 and the fact that it might be a possibility that we are not talking about the same cases between countries, we want to clarify this case a bit.

The cases we would like to remove from DRG 103 are what is now called the paracorporeal VAD, code FXL20 in the Norwegian version from 2017 (earlier this cases were covered by the code FXL30 extracorporeal VAD). In Norway the definitions are presented like this in accordance with the primary classification:

FXL Innlegging av VAD
VAD (Ventricular assist device) klassifiseres dels etter pumpens plassering, dels etter metode for innlegging.
Intrakorporal og ekstrakorporal VAD:
• legges inn ved åpen torakskirurgi
• intrakorporal har pumpen inne i kroppen
• ekstrakorporal har pumpen utenfor kroppen

Parakorporal VAD:
• legges inn perkutant transluminalt
• kan ha pumpen inne i eller utenfor kroppen

The costs for different types of ventricular assist devices, including the costs for the entire hospital stay vary from approx. 500’ NOK to 2 000’ NOK due to costdata (KPO) from Oslo University Hospital, while the costs for an heart transplantation will be approx. 1700’-2000’ NOK.
The paracorporeal VAD (FXL20) includes the Impella® Heart Device/ Circulatory Support system which “is a minimally invasive percutaneous cathether based support device, designed to provide partial circulatory support” (Abiomed Inc).
Due to the costs for parakorporeal VAD (FXL20) it is obvious that this does not fit too well in DRG 103. The Norwegian data show that it fit quite well in DRG 483B, both regarding the costs and the medical description.

#10 Updated by Martti Virtanen over 4 years ago

2017-03-13 Expert group
Accepted for NOR version.
In the NCSP+ new codes for intra/para/extracorporeal VAD's i s needed.
The case will affect only extracorporeal VAD, others will have the previous properties.
A new property and new rule is needed. Technical changes needs to be changed.

#11 Updated by Martti Virtanen over 4 years ago

  • File Technical changes case #478 new.xlsx added

2017-05-15 Martti Virtanen
FXL30 'Insertion of extracorporeal VAD (Nor)' is very close to FZSD00 'Use of extracorporeal heart and lung assistance (ECHLA) without concurrent surgical procedure'. FXL30 does not include Lung assistance but otherwise the intervention includes the same elements. FZSD00 has already the property 00S20 'Intensive circulatory support' that is needed. For some reason it does not have property 14S90 'Significant operation for obstetrical patient'. Howerver, this property has effect on DRG assignment only in very theoretical situations.
The new technical changes document whows the neccessary changes (only in NCSP+)

#12 Updated by Martti Virtanen over 4 years ago

2017-05-29 Martti Virtanen
In the technical changes the rows in table Proc were mixed. This is now corrected. The NCSP+ codes shall have the properties they have had previously.

#13 Updated by Martti Virtanen over 4 years ago

  • File deleted (Technical changes case #478 new.xlsx)

#14 Updated by Kristin Dahlen over 4 years ago

The cases we would like to remove from DRG 103 from 2018 are what is now called the paracorporeal VAD, code FXL20 (earlier this cases were covered by the code FXL30 extracorporeal VAD). Due to a change in codes in this area from when this case (478) were generated, this might have caused confusion.

#15 Updated by Martti Virtanen almost 3 years ago

  • Status changed from Further active to Accepted

2018-03-13 Expert group
The Norwegian problem is solved by correction to the NCSP+ mapping.
The NDMS-Com version tables need no further changes.
The case is accepted and closed.

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