Case #540

Procedures for ingrown nails

Added by Mats Fernström about 2 years ago. Updated about 1 month ago.

Status:AcceptedStart date:2017-02-22
Priority:MinorSpent time:-
Assignee:Mats Fernström
Target version:Target version 2018
Initiator:Sweden Target year:2018
Case type:Minor Owner / responsible:National organisations
MDC:MDC09 Old forum status:
Target Grouper:SWE


Problem & Analysis
Operations for ingrown nails:
• QCH10/QCSH10 ’Excision av fingernagelbädd’/Excision of nail bed in finger
• QCH20/QCSH20 ’Korrektion av deformerad fingernagel’/Correction of deformity of finger nail
• QDH10/QDSH10 ‘Excision av tånagelbädd’/Excision of nail bed in toe
• QDH20/QDSH20 ’Korrektion av deformerad tånagel’/Correction of deformity of toe nail
are usually performed in ZXH20/WAA299 ‘Other minor blockade of peripheral nerve’ and they used to be grouped to DRG J39O ‘Andra operationer vid sjukdomar i hud och underhud, öppenvård’ (former DRG 270O ‘Other skin & subcutaneous tissue procedures, short therapy’) according to the rule with ORD 109D130210 based on PROCPRO 09S08 and DGPROP 00X10, the latter from the anesthesia code.
In NordDRG 2017 however, DGPROP 00X10 was deleted from ZXH20/WAA299 according to case #462 and now the cases with these operations are grouped to the conservative outpatient DRG J50O ‘Läkarbesök vid inflammation i hud & underhud’ (part of the former DRG 909O ‘Disease or disorder of the skin and subcutaneous tissue system, short therapy w/o significant procedure). This is not good, neither from a medical nor from an economic perspective. The average cost for these patients is approx. 10 000 SEK (see Appendix C672.xlsx). This seems rather high and probably there are some patients with general anesthesia in the cost data base. Nevertheless, the surgery is done with sterile conditions and bloodless field and it is absolutely more expensive than the average cost for DRG J50O, that is only 2 700 SEK. These patients fit better in DRG J39O (average cost 6 400 SEK) where they used to be but we don’t want to reintroduce DGPROP 00X10 to ZXH20/WAA299. A better solution is to give the current procedure codes a new PROCPRO and construct a new rule based on that PROCPRO that leads to DRG J39O/270O without requiring DGPROP 00X10.
NPK, Sweden – 2017-02-19
Operations for ingrown nails (procedure codes mentioned above) are grouped to DRG J39O/270O like they used to be instead of the present grouping to a conservative DRG without significant procedures. The technical changes depend on whether this is accepted for the Common version or not.
Alternative 1, the change is accepted for the Common version.
A new PROCPRO, 09S10 ‘Procedure for ingrown nails’ is inserted in the table “proc prop”.
This PROCPRO is added to the procedure codes mentioned above instead of the present 09S08 in the table “proc1”.
A new rule is inserted in the table “drglogic” immediately after the last present rule for DRG J39O/270O. This rule is a copy of the last rule for DRG J39O/270O but 09S08 is changed to 09S10 and 00X10 is deleted.
Alternative 2, the change is done only in the Swedish version
In principle, the same technical changes as in alternative 1 but the new PROCPRO will be 09V10 instead of 09S10.
Decided changes
NPK, Sweden – 2017-02-19
If alternative 1 is rejected, alternative 2 will be introduced unilaterally in the Swedish version for 2018.
DRG change
Outpatient cases with any of the procedure codes mentioned above that in version 2017 are grouped to conservative DRGs will instead be grouped to DRG J39O/270O as in version 2016 and earlier.
Technical change
Already mentioned above. Detailed technical changes are in the Excel file Suggestion_Decision C672.

Appendix C672.xlsx (11.7 KB) Mats Fernström, 2017-02-22 11:38

Suggestion_Decision C672.xlsx (22.9 KB) Mats Fernström, 2017-02-22 11:38

TC #540 C672.xlsx (21.9 KB) Ralph Dahlgren, 2017-04-11 14:08

Technical changes case #540.xlsx (21.7 KB) Martti Virtanen, 2017-04-11 17:40

Technical changes case #540-2.xlsx (26 KB) Martti Virtanen, 2017-08-28 15:51

Technical changes case #540-3.xlsx (26.2 KB) Martti Virtanen, 2017-09-14 15:05

Technical changes case #540-4.xlsx (26.4 KB) Martti Virtanen, 2017-09-22 16:34

TC #540 C672 New.xlsx (16.5 KB) Mats Fernström, 2017-10-05 16:12

NDRG com 2018 for 09S07, 09S08 and 09S10 rules.xlsx (1.13 MB) Martti Virtanen, 2018-02-21 14:37

Technical changes case #540-5.xlsx (31.5 KB) Martti Virtanen, 2018-02-21 14:37

Technical changes case _540-5 Comments SWE.xlsx (37.7 KB) Mats Fernström, 2018-03-08 12:49

Technical changes case #540-6.xlsx (41.1 KB) Martti Virtanen, 2018-03-12 10:09


#1 Updated by Kristiina Kahur about 2 years ago

Finnish National DRG-centre 2017-3-3

Finnish cost data support the change (Alternative 1).

#2 Updated by Martti Virtanen about 2 years ago

2017-03-08 Martti Virtanen
The property 09S10 is a new one and does not affect any version if not the logic change is also peformed.
The countries need to decide wether theys use the new rule or not.
The property 09S08 can be retained if any of the countries wishes to continue to use of the old grouping.
09V10 is not needed.

#3 Updated by Ralph Dahlgren about 2 years ago

2017-03-13 Expert group
On the Expertgroups meeting march 2017 it was deicided that the approval was for suggestion number one. Enclose today technical Changes just for suggestion number one.

#5 Updated by Kristiina Kahur almost 2 years ago

Kristiina Kahur/Finnish National DRG-centre 2017-4-28

As agreed in the meeting, Finland would like this change in 2018 Finnish version.

#6 Updated by Martti Virtanen almost 2 years ago

  • File Technical changes case #540-2.xlsx added

2017-04-28 Martti Virtanen
Finland wants the change also.
Technical change for combined version included.

#7 Updated by Mats Fernström almost 2 years ago

Mats Fernström, NPK, Sweden, 2017-05-03
QCSH10 'Excision av fingernagelbädd' is missing in "Technical changes case #540-2.xlsx".

#8 Updated by Martti Virtanen over 1 year ago

2017-08-28 Martti Virtanen
The proposal has from beginning an error because the codes at issue happen to have 09S08 instead of 09S07 that would be more logical.
Therefore 09S08 is not removed as it is not marked for 'OUT' in technical changes.

Taking a second look at the case it is obvious that the removal of 09S07/09S08 is not necessary because it only results in assignment to the same DRG if the patient has been in anaesthesia. Additionally this is necessary for the versions that do not use the new rule because the removal would potentially change grouping in these versions.

The property 09S07 is changed to 09S08 because the 09S07 is wrong and not logical.
The technical changes have bee corrected accordingly

#9 Updated by Martti Virtanen over 1 year ago

  • File deleted (Technical changes case #540-2.xlsx)

#10 Updated by Mats Fernström over 1 year ago

Mats Fernström, NPK, Sweden 2017-08-29
As I understood, the meeting decided to accept the proposal for all national versions, and then neither 09S07 nor 09S08 are needed for the codes at issue, at least not for the outpatient grouping. But if any nation has declared that they don’t accept the proposal, I agree with Martti that 09S07/09S08 cannot be removed. And it could perhaps be wise to keep 09S07/09S08 for the inpatient grouping.
But I do not understand Marttis comment on changing the property 09S07 to 09S08 “because the 09S08 is wrong and not logical”. It is probably a mis-printing because it makes no sense to change to something wrong. Marttis latest technical changes are also somewhat confusing. Procedure property 09S07 is replaced with 09S08 for some of the four codes at issue but deleted for some. I think that Martti has to clarify this case at the expert meeting next week.

#11 Updated by Martti Virtanen over 1 year ago

2017-09-11 Martti Virtanen
The intervention QDSH20 needs the property 09S07/09S08 for other versions than Swe and Fin.

In the new grouping (for Swe and Fin):

For outpatients if QDSH20 has both 09S07 and 09S10 the cases with MDC 09 and QDSH20 are assigned to DRG 270O either with 09S07 + anaesthesia or with 09S10. If QDSH20 has 09S08 all cases are assigned to DRG 270O with 09S08.

For inpatients if QDSH20 has both 09S07 (and 09S10) cases with 09S07 are assigned to conservative groups if no anaesthesia is specified. With anesthesia the cases are assigned to DRG 269 (M/C/X). If QDSH20 has 09S08 the cases are allways assigned to DRG 269 (M/C/X)

The correction of nails with anaesthesia is a significant interention and the assignment to DRG 269 is probably more correct than coservative groups. Thus because we cannot take out both 09S07 and 09S08, I think we should retain 09S07.

#12 Updated by Martti Virtanen over 1 year ago

2017-09-14 Martti Virtanen
Because of demand from Sweden, I made a new version of technical changes following my proposal above. The change actually turns everything back as it used be for those who do not use the new rules. For Swe and Fin the situation should be as described above.

#13 Updated by Mats Fernström over 1 year ago

Mats Fernström, NPK, Sweden 2017-09-14
Technical changes case #540-3.xlsx are still contradictory about 09S07 and 09S08!
I agree with Martti that we shall keep 09S07 because, for inpatients, 09S08 is always leading to the surgical DRG J39A/C/E (former 269 or 270) irrespectively if there is OR property or greater anesthesia. The current procedures in this case are not of such a size that they should affect the grouping of inpatients unless there is greater anesthesia. So on this point we agree but the latest changes (Technical changes case #540) are still contradictory, in the sheet “proc”. They say that 09S08 shall be added to QCSH10 and nothing about adding 09S07 to any code.
How we write the technical changes depends on what version we start from, but I hope that we can agree on the following for all the four current procedure codes:
• If 09S07 is present, it must be retained.
• If 09S08 is present, it must be replaced by 09S07.
• If neither 09S07 nor 09S08 is present, 09S07 must be inserted.
• (The alternative both 09S07 and 09S08 doesn’t exist in the Swedish version but if present in any other version, 09S08 must be deleted.)

Looking at this case, I found that the rules for DRG J39O based on 09S08 demand either OR=1 or greater anesthesia, which is peculiar since the corresponding rules for inpatients (DRG J39A/C/E) don’t have this demands. We don’t want any changes of this for now, but we will analyze the problem and make a new case on this.
At the same time, we should probably look at which codes should have 09S07 and which ones should have 09S08. In a quick review, I have difficulty seeing basic differences between the codes that have one or the other property.

#14 Updated by Martti Virtanen over 1 year ago

2017-09-22 Martti Virtanen
I agree with Mats about the current case. In my previous correction I only looked at QCSH20 that was the previous problem.
However, Mats has right the same problem is valid for all codes in the group!
That meaans that we cannot just remove 09S08 from the codes, because it will affect all versions!
The smallest modification is just to add 09S07 to all codes in the group that do not have it yet and remove 08S08 from all codes that have it now.
If this is not acceptable, we must probably cancel the case for further discussions.
I have added a new technical changes file.

#15 Updated by Mats Fernström over 1 year ago

Mats Fernström, NPK, Sweden 2017-10-05
We seem to agree on what grouping properties QCSH10, QCSH20, QDSH10 and QDSH20 should have but Martti's "Technical changes case # 540-4.xlsx" is still somewhat difficult to understand and somewhat contradictory. For example, it is stated that 09S08 should both be removed from and added to QDSH20. I attach technical changes (TC # 540 C672 New.xlsx) for the Swedish SOS version (SWE2018-PL1-SOS).

#16 Updated by Kristin Dahlen over 1 year ago

  • Subject changed from Procedures for ingrown nails to DRG 470 - rule regarding normal newborn and intensive care prosedures
  • Assignee changed from Mats Fernström to Kristin Dahlen
  • Target Grouper NOR added
  • Initiator Norway added

Because of the Norwegian rules for coding and aggregation to hospital stays, we do have problem with the following rule:

ord drg rtc icd mdc pdgprop or procpro1 dgcat1
015D80002 470 Ikke grupperbar pga manglende opplysninger 9 + 15S02 15M02

We also see this rule as a kind of rule to take care of bad coding. We therefore have concluded to take this rule out of the Norwegian version for 2018.

#17 Updated by Kristin Dahlen over 1 year ago

  • Subject changed from DRG 470 - rule regarding normal newborn and intensive care prosedures to Procedures for ingrown nails
  • Assignee changed from Kristin Dahlen to Mats Fernström
  • Target Grouper SWE added
  • Initiator Sweden added

#18 Updated by Martti Virtanen over 1 year ago

  • Status changed from Active to Further active

2018-01-09 Martti Virtanen
We need to check this case once more at the next expert meeting.
I will try to understande what we want!

#19 Updated by Martti Virtanen about 1 year ago

2018-02-21 Martti Virtanen
The problems that we have had with this case are due to an error that we have made earlier. This can be seen in the set of tables taken from NordDRG Com 2018 attached to this case.

The properties we are dealing with are:
09S07 'Other skin, subcutaneous tissue or breast procedure'
09S08 'Other skin, subcutaneous tissue or breast procedure, not OR procedure'
09S10 'Procedure for ingrown nails'
Althought 09S07 does not state it, it means that the interventions with this property must be OR=1 type. 09S08 clearly states that the procedures of this type cannot be of OR=1 type. This was originally the case but we have changed OR-levels of the propeties without changing the 09S07 and 09S08 as we should have done. Therefor the logic has rules for 09S07 with anaesthesia, that should not exist.
This needs to be correcct by giving the interventions without OR=1 the property 09S08 instead of 09S07.
There is also a code (PXXX00 'Biopsy of artery or vein') that has 09S08 and OR=1. It must be given 09S07 instead of 09S08.
These are now included in the new technical changes table.
These changes will not affect DRG assigment since the cases will be assigned by the rule with 09S08 or by the rule with 09S07 and OR=S to the same DRG as before.

The procedures QCDSH10, QCDSH20, QDSH10 and QDSH20 are not OR=1 interventions and therefore they must have 09S08. For some reason that is not quite clear to me, the Swedish outpatient rules for DRG 270O/J39O demands OR=1 or anaesthesia (what also Mats was wandering 2017-09-14). The need for 09S10 property is caused by that phenomen and only by it.
This rule (OR=1 / 00X10 demand) obviously limits other DRG 270O/J39O to cases with either more significant interventions (09S07) or less significant interventions with 'greater' anaesthesia. The interventions with 09S10 will make an exception to this.

To make this happen, we need to add the new rule with 09S10 to the Swedish version. It is not needed in the Finish that does not demand 'greater' aneaesthesia for outpatient cases with 09S08 to be assigned to DRG 270O. (The rule 109D130221 will be taken OUT!)

The procedures QCDSH10, QCDSH20, QDSH10 and QDSH20 must not have 09S07, the existing and added properties will be removed. They must have 09S08. It will be added or reinstalled. Please note that these codes also had errors for 09S07/09S07 in earlier versions.

#20 Updated by Mats Fernström about 1 year ago

Mats Fernström, NPK Sweden 2018-03-08
I appreciate Martti's desire to bring order to the codes with 09S07 and 09S08 and accept in principal his technical changes and I have just a few comments (se Technical changes case _540-5 Comments SWE.xlsx):
• The suggested changes for QDSH10 ‘Excision of nail bed in toe’ and QDSH20 ‘Correc-tion of deformity of toe nail’ are somewhat unclear but I think that 09S07 must OUT (as stated by Martti in the text above) and then I don’t understand the comment “QDSH20 will retain the property 09S07 instead of 09S08” in the sheet “Read me”.
• There are more codes with 09S07 but not OR=1 and according to Martti’s statement in the text above they also should have 09S08 instead of 09S07. They are listed in the sheet “additional proc” in Technical changes case _540-5 Comments SWE.xlsx.
• The codes with 09S08 ‘Other skin, subcutaneous tissue or breast procedure, not OR procedure’ are relatively small compared to the codes with 09S07 and it must be an error that these codes directly affect the grouping of inpatients without any demand for OR=1 or greater anesthesia. Such demands are present in the rules for the outpatients and they should be inserted also in the rules for inpatients in the table Drglogic.

#21 Updated by Martti Virtanen about 1 year ago

2018-03-12 Martti Virtanen
Mats has right- there is a larger number of interventions with 09S07 without OR=1. I think they should be corrected.
The two overlinde rows were supposed to be added, but should not.
I added all affected codes to NCSP+ sheet of the technical changes.

#22 Updated by Kristiina Kahur about 1 year ago

Finnish National DRG-Centre/Kristiina Kahur 16-4-2018

Just checking whether the last added technical changes By Martti are the correct ones or will there any other changes?

Thank you, Kristiina

#23 Updated by Martti Virtanen 4 months ago

2018-03-13 Expert group
The proposal was accepted as proposed.
The 09S07 => 09S08 changes will be discussed as new case (#613) next year

#24 Updated by Martti Virtanen about 1 month ago

  • Status changed from Further active to Accepted

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