Case #577

Catheter-based valve implantation

Added by Anja Fagervold over 2 years ago. Updated over 1 year ago.

Status:AcceptedStart date:2018-01-24
Priority:NormalSpent time:-
Assignee:Anja Fagervold
Target version:Target version 2019
Initiator:Norway Target year:2019
Case type: Owner / responsible:Nordic Casemix Centre
MDC:MDC05 Old forum status:
Target Grouper:COMMON


Oslo University Hospital is performing implantations of valve protheses (children and adults). A limited number valves can be implanted by catheter based procedures. Valves of the same type can be placed in different locations of the heart. Type of surgery is approximately the same regardless of position of the valve, and the cost of the implant itself is approximately equal, and the same type of valve can be used in different positions. It is therefore illogical with different reimbursement depending on implant location.

We suggest to unite the following procedures in the same DRG 104C:
FKK72A Perkutan transluminal innsetting av mitralimplantat
FJK12A Perkutan transluminal implantasjon av biologisk pulmonalklaffeprotese
FMK12A Perkutan transluminal implantasjon av biologisk aortaklaffprotese
FMK14A Perkutan transluminal implantasjon av biologisk aortaklaffeprotese

FMK12A and FMK14A is by now the only procedures grouped to DRG 104C. FKK72A and FJK12A is grouped to DRG 104 A.

The new DRG 104C could be named «Kateterbasert implantasjon av hjerteklaff».

In 2017 there are 428 cases where one of these four procedures is performed. The cases are most often grouped to 104C (394 cases) and most cases belongs to Oslo University hospital (192 cases).

The weight for DRG 104C is 7,459 and for DRG 104A it is 5,314.

We suggest to group FKK72A and FJK12A to DRG 104C instead of 104A.

DRG change
104C is renamed to «Kateterbasert implantasjon av hjerteklaff».

Technical change
We suggest to group FKK72A and FJK12A to DRG 104C instead of 104A by adding
PROCPRO 05S80 on the procedures FKK72A and FJK12A.

proc: procpro 05S80 is added to FJK12A and FKK72A
drgnames: DRG 104C is renamed

Technical changes_case 577.xls (79 KB) Anja Fagervold, 2018-01-24 14:26

Technical changes case #577.xlsx (66.4 KB) Martti Virtanen, 2018-03-05 13:46

TC_C736_#577_2018-04-04.xlsx (19.5 KB) Mats Fernström, 2018-04-04 18:28

Technical changes case #577-2.xlsx (66.2 KB) Martti Virtanen, 2018-04-16 15:38

Technical changes case #577-3.xlsx (66.3 KB) Martti Virtanen, 2018-10-17 12:15


#2 Updated by Kristiina Kahur over 2 years ago

Finnish National DRG-Centre 7-2-2018

There is no code in Finnish version which would correspond to NOR code FKK72A. To code FJK12A corresponds code FJF12 in Finnish version. There is no use of code FJF12 2014-2016.
From clinical point of view the change may make sense. However, we cannot provide any cost data to support it.

#3 Updated by Mats Fernström over 2 years ago

Mats Fernström, NPK, Sweden, 2018-02-22 (NPK ID C736)
There is no Swedish procedure code mapped to FKK72A, but FJK12A is mapped to FJF12 ‘Perkutan transluminal implantation av biologisk pulmonalklaffprotes’ and we support that it is allocated to the suggested DRG 104C, which corresponds to the Swedish DRG E03N that already has a proper text (Perkutan implantation av hjärtklaff). We have no reliable cost data because we had only one case per year with FJK12A/FJF12 in the cost databases for 2015 and 2016, but for medical description we think that it is obvious that an allocation of FJK12A/FJF12 to a DRG for percutaneous approach is better than allocation to a DRG for open heart surgery.
Thus we want the suggested change also in the Swedish version and we just want to add that the text to the procedure property 05S80 should be changed from “Transcatheter Aortic Valve Implantation” to ”Transcatheter heart valve implantation”.

#4 Updated by Martti Virtanen over 2 years ago

2018-03-05 Martti Virtanen
The proposal is very intresting and deals with a problem that is somewhat hidden in NCSP+ mappings.

The technical changes document includes in the NCSP+ -sheet with all valve interventions (FGS, FJS, FKS, FMS)
I have devided the codes to transluminal valve interventions (translum valve), transluminal no valve (translum no valve), transapical valve (transapic valve) and mostly open interventions (open?).
This analysis revealed some obvious problems in the mappings ( FKE10, FKE50, FM1AT, FME60 and FME90 from Finnish CSP, KFM10 from Danish CSP and FMD15 from Finnish CSP - The last one not related to percutaneous method). I have proposed corrections for these. The corrections will lead to addtion of property 05S80 to these codes (except Fin - FMD10).

The property 05S80 currently 'Transcatheter Aortic Valve Implantation' should obviously be renamed. Mats Fernström proposed 'Transcatheter heart valve implantation' which is clearly better than the current one. However, since among the included interventions is already 'Transapical replacement of mitral valve' (FKSD97) maybe the property should be called 'Percutaneous heart valve intervention'.
This terminology would leave out transluminal 'expansion' and 'transluminally inserted clip' from the percutaneous valve interventions. Obvioulsy the interventions that are presumed to be open are not icluded.

The outpatient grouping is currently based on property 05S02 'Cardiac valve procedure' that all codes at issue have. The inpatient grouping starts with the rule with 05S80 followed by groups based on 05S02. This means that patient cases where both open and 'percutaneous' interventions have been performed will be assigned to 'percutaneous' group. It is probable that such cases exist or will exist in some situations and if so, the order of rules is not optimal.
The optimal order would be, that the rule with 05S80 would be placed after the 05S02 rules. The question is how far? There are number DRG's for mostly open heart surgery that are probably more resource needing and in principle should be before the percutaneous interventions (and may happen to be performed on the same contact. Obviously 'Percutaneous heart valve intervention' should be before DRG 124X 'Diagnostic percutan cardiac procedure w circulatory complex dx' (ID 405D200000/405D2000001) since the last named is only diagnostic intervention. However, this consideration needs economical analysis on resource use for the DRG's in between.
For the last named solution the 05S02 property must be removed from the codes with 05S80 and the outpatient logic must have added rules for 05S80 (with for outpatients same DRG as rules for 05S02). Then 05S02 would not be added to the new codes that must have 05S80.

The DRG 104C will in practise have the meaning 'Percutaneous heart valve implantation' as proposed by Norway. And as noted by Mats Fernstrom it is the same as the Swedish DRG E03N. There fore these DRG's should be linked to 104D instead of 104C that is linked to another DRG in the Swedish version. Since the content of the DRG changes it is logical that the coding also changes.

Despite of the extensive changes the result will be what Norway orginally proposed. With the improvement that patient cases with both open and percutaneous interventions will be assiged to DRG's for open surgery and cases with only percutanoeus intervetnions to the 'percutaneous' group.
For Finland the change of mapping of a few interventions may cause some changes in DRG assignment. For Sweden there will be changes only for the patient cases with both open and percutaneous interventions (on the same contact). For othe countries the coding and name of the DRG also changes.

This case that looked like simple but prooved to be quite complex. Hope you can follow the changes.

#5 Updated by Mats Fernström over 2 years ago

Mats Fernström, NPK Sweden 2018-04-04 (Swe ID C736)
We accept that 05S80 is renamed to “Percutaneous heart valve implantation”. We also accept that 05S02 is replaced by 05S80 for the procedure codes for percutaneous or transapical or transluminal replacement of heart valves but not for the codes for “expansion”, “repair” or “correction” of heart valves mentioned in Martti’s file Technical changes case #577.xlsx. This means that the following NCSP+ codes shall have 05S80 and not 05S02:
•FJSF12 Percutaneous transluminal replacement of pulmonary valve using biological prosthesis
•FKSD02 Percutaneous replacement of mitral valve using mechanical prosthesis
•FKSD97 Transapical replacement of mitral valve
•FKSD98 Transluminal mitral valve replacement, valve-in-valve
•FMSD12 Percutaneous transluminal replacement of aortic valve using biological pros-thesis
•FMSD13 Percutaneous transapical replacement of aortic valve using biological pros-thesis
•FMSD19 Other transluminal replacement of aortic valve
The corresponding Swedish codes are only:
•FJF12 Perkutan transluminal implantation av biologisk pulmonalklaffprotes
•FMD12 Perkutan transluminal implantation av biologisk aortaklaff
•FMD13 Perkutan transapikal implantation av biologisk aortaklaff
The reason why only codes for replacement shall have 05S80 is that the prosthesis is very, very expensive. It is not the same prosthesis as used in open heart valve replacements and in fact, the prosthesis is so expensive that the cases cost almost the same as the cases with open heart valve replacements. This is also the reason why we don’t accept to move the rule for DRG E03N (DRG 104D in Common) so far down as suggested by Martti. The average cost for DRG E03N is 313 282 SEK (Swe KPP 2016) and the only DRG for open heart valve replacements that is more expensive is DRG E04A ‘Operation av hjärtklaffar, mycket komplicerat eller flera komplicerade’ (366 244 SEK) so we accept to put the rule for DRG E03N between the rules for DRG E04A and DRG E04C. There are other surgical DRGs in MDC 05 that are more expensive than DRG E03N and with rules further down in the hierarchy, but the procedures in those DRGs are most likely not performed together with heart valve replacements during the same episode.
Finally we accept the outpatient rule based on 05S80 but it must lead to the same existing DRG as 05S02, namely DRG E05O ‘Operation av hjärtklaffar, öppenvård’. There is no need for a separate outpatient DRG for percutaneous heart valve implantations. (Also the need for DRG E05O can be questioned but that will be in another case.)
Technical Changes for the Swedish version are specified in TC_C736#577_2018-04-04.xlsx_.

#6 Updated by Martti Virtanen about 2 years ago

2018-03-12 Expert group
Expert group agreed on the princples. The location of the rules with 05S80 need correction as well the list of codes with 05S80 or with 05S02.
See Mats Fernström comment above and NCC comment below.

#7 Updated by Martti Virtanen about 2 years ago

  • File Technical changes case #577-2.xlsx added

2018-04-16 Martti Virtanen
I agree with Sweden about the changes.
The combined changes for all versions are included in the new technical changes.

The proc sheet is now by default filtered for procedures with 05S02 and 05S80. The principle from the Expert group was as Mats states that intervention with transcutaneous insertion of artificial valve are currently very expensive and need special treatment. These intervetions will now have 05S80. The other valveinterventions shall have 05S02. (See proce sheeet)
The logic needs an upgrading of the 05S80 rules from my proposal. The Swedish rule is moved below the CC-groups but before non-CC group. The rule for the other versions is after their CC-rules.

#8 Updated by Martti Virtanen about 2 years ago

  • File deleted (Technical changes case #577-2.xlsx)

#10 Updated by Martti Virtanen over 1 year ago

2018-10-17 Marti Virtanen
The code FMSD13 (/FMD13/FME30)'Percutaneous transapical replacement of aortic valve using biological prosthesis' has lost the property 05S02 as proposed by Mats Fernström 4.4.2018. The change is not included in technical changes but it is now changed in all versions because this is a common property. This was noted by Finland.
The change is not important, the intervention is very rare. However, the question is, how demanding the transapical intervention actually is. Should it still have the heavy intervention property 05S02 or only 05S80.
We leave the properties as they are now, i.e. no 05S02 for FMSD13 but I leave this case open for discussion at the expert group next spring.
The version 3 of technical changes includes this new change.

#11 Updated by Martti Virtanen over 1 year ago

  • Status changed from Active to Accepted

2018-03-13 Expert group
Expert group accepted the changes.

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