Case #580

Vagus nerve stimulation for depression

Added by Mats Fernström 10 months ago. Updated about 1 month ago.

Status:ActiveStart date:2018-01-25
Priority:MinorSpent time:-
Assignee:Mats Fernström
Category:-
Target version:Target version 2019
Initiator:Sweden Target year:2019
Case type:Minor Owner / responsible:National organisations
MDC:MDC19 Old forum status:
Target Grouper:COMMON

Description

Problem
The procedure code ADB00 ’Inläggande av vagusnervsstimuleringsutrustning’ (in NCSP+ ADSB00 ’Implantation of vagus nerve stimulating device’) is grouped to DRG A20 ‘Implantation/byte av nervstimulator …’ (former DRG 570/570O ‘Insertion or replacement of nervous system central stimulation device’) when the principal diagnosis is epilepsy (MDC 01). Vagus nerve stimulation is approved also for the treatment of chronic or reccurring depression, however, but with principal diagnoses in MDC 19, ADB00/ADSB00 will not be grouped to DRG A20/570/570O but instead to the very unspecific DRG T01 ‘Operationer vid psykiska besvär …’ (former DRG 424N/O ‘O. r. procedure w principal diagnos of mental illness or abuse …’). This is not logical. We want that the cases with implantation of vagus nerve stimulating device are grouped to DRG A20/570/570O also when the principal diagnosis is in MDC 19. Cost analysis is not needed.
Norway does not have this problem with the inpatients because they already have a rule with ORD 400D900000 for any MDC. (This rule in the pre-MDC area may cause another problem that Norway has to deal with. If a CNS stimulation device is inserted and another much greater intervention is performed during the same episode, the case will still be grouped to DRG 570.)
Suggestion
NPK, Sweden – 2018-01-25. NPK ID C711.
Cases with implantation of vagus nerve stimulating device (ADB00/ADSB00) and a principal diagnosis in MDC 19 should be grouped to DRG A20/570/570O instead of DRG T01/424N/O. This is already the situation for inpatients in Norway.
DRG change
Cases with implantation of vagus nerve stimulating device (ADB00/ ADSB00) and a principal diagnosis in MDC 19 are grouped to DRG A20/570/570O instead of DRG T01/424N/O. No DRG change for inpatients in Norway.
Technical change
• A copy of the present rule for DRG A20O/570O (ORD 101D0590001 in SOS version and ORD 101D059000 in COMMON version) but with MDC 01 exchanged to MDC 19 is inserted before the first rule for DRG T01O/424O. Some ORD changes for the first rules for DRG T01O/424O must be done to make spaces for the new rules in the 119D area. See TC_C711.xlsx for details.
• A copy of the present rule for DRG A20N/570 (ORD 401D060000 in SOS and COMMON and ORD 401D059000 in FIN) but with MDC 01 exchanged to MDC 19 is inserted before the first rule for DRG T01N/424N. This is not needed in the Norwegian version because the rule with ORD 400D900000 covers all MDCs. See TC_C711.xlsx for details.

TC_C711.xlsx (15.2 KB) Mats Fernström, 2018-01-25 16:29

Technical changes case #580 & #587.xlsx (33.2 KB) Martti Virtanen, 2018-03-06 15:20

Technical changes case _580 & _587 Comments MF.xlsx (33.9 KB) Mats Fernström, 2018-04-05 17:09

TC_#580&587_C711&741_2018-04-05.xlsx (25.1 KB) Mats Fernström, 2018-04-05 17:10

Tiedoston Technical changes case #580 & #587 version 2.xlsx (33.1 KB) Martti Virtanen, 2018-10-08 17:21

Drglogic for A20O A21N A22N in SWE 2019 PL.xlsx (11.3 KB) Mats Fernström, 2018-10-10 13:02

History

#1 Updated by Kristiina Kahur 9 months ago

Finnish National DRG-Centre 8-2-2018

One case with combination of maindx from MDC19 and ADB00 in 2015 in Finnish data only, resulting in DRG 424N. In 2014 and 2016 no such cases. The impact of the change would be very low. From clincial point of view the suggestion is logical and we support it.

#2 Updated by Mats Fernström 9 months ago

Mats Fernström, NPK Sweden 2018-02-13
Note that case #587 is an extension of this case, but just concerning inpatients. If case #587 is accepted, the technical changes for inpatients described here in #580 must not be done!

#3 Updated by Martti Virtanen 9 months ago

  • File Technical changes case #580.xlsx added

2018-03-05 Martti Virtanen
I have a difficulty with the proposed change.
The DRG's 424O and 424N 'O. r. procedure w principal diagnos of mental illness or abuse' for outpatients and inpatients are indeed extremely unspecific. There is definetely need for differentiation of specific treatment of psychiatric problems with interventions.

Vagal nerve stimulation has been used since more than 10 years for anxiety and the conditions for which it is used include even schizophrenia. To assign these clear psychiatric cases to a neurological DRG does not seem correct.

The procedure property 01S51 includes a number of interventions that at least currently have not associated with psychiatric therapy. If the patient has psychiatric principal dx, it is questionable where they should be assigned.

There is no case for the Norwegian change of adding a new rule for DRG 570X at ord 400D900000 and thus it has not been discussed. In addition to overruling any other combination of dx and intervention as described by Mats Fernström, it makes the rules 401D060000 and 419D011000 not applicable, since all cases are already assigned by rule 400D900000.
Thus, if the proposal is accepted the rule 400D900000 should be inactivated and the new rule used also for Nor-version.

#4 Updated by Martti Virtanen 8 months ago

2018-03-06 Martti Virtanen

Case #587 clearly improves case #580. It makes possible to group only vagus stimulation in MDC 19 the specified DRG.
Therea are much less changes needed that Swe has proposed. As long as property 01S51 is retained for all interventions, the order of rules takes care of the correct assignment.

Since this is really a compined case, the technical changes are combined. They are written as the other countries would stay in their old versions, but can be easily modified.

I am still concerned about combining psychiatric cases with neurological.

#5 Updated by Martti Virtanen 8 months ago

  • File deleted (Technical changes case #580.xlsx)

#6 Updated by Mats Fernström 7 months ago

Mats Fernström, NPK Sweden 2018-04-05 (Swe ID C711&741)
I have checked the file Technical changes case #580 & #587.xlsx and found some few errors. See my file Technical changes case _580 & _587 Comments MF.xlsx. Corrections that should be done are marked with red characters and my comments are in a column to the right. Among the most important things are that some ID and ORD have been mixed up which is easily done since these columns are in opposite order in the definition table Drglogic. The template for technical changes should have the same order as the definition table!
Furthermore, since we have divided the DRG A20N (570) we no longer want the inpatient rule based on 01S51 in the MDC 19 area that we suggested in case #580. This is because the rule includes other things than implantation of vagal stimulator.
And once again, Norway has to decide what to do with the rule with ORD 400D900000. That rule will make all changes further down in Drglogic impossible for Norway.
I include the file for technical changes in the Swedish SOS version (TC#580&587_C711&741_2018-04-05.xlsx_) for information.

#7 Updated by Hanne Osnes-Ringen 7 months ago

As far as I understand, we do not have any problem with grouping of this procedure in Norway. We have 138 cases a year. All of these cases except 3, group to 570 or 570O. DRG 570 and 570O includes similar procedures and no other greater interventions in these DRGs. We therefore would not like to do any changes concerning this case.

#8 Updated by Mats Fernström 7 months ago

Mats Fernström, NPK Sweden 2018-04-11 (Swe ID C711 & C741)
The rule with ORD 400D900000 causes no problem as long as you don’t want the new DRG 571 that Swe and Fin will introduce, but Martti should then delete “Nor” in the field “nat_ver” on the rules with ORD 401D060000 and 419D0109900 because these rules are impossible - all cases with these procedures are grouped according the rule with ORD 400D900000.

#9 Updated by Martti Virtanen about 1 month ago

2018-10-08 Martti Virtanen

Sweden has changed the original proposal.

DRG 570 is divided to 2 new DRG's:
570 (A20N) ‘Insertion or replacement of nervous system central stimulation device’

570? (NordDRG Swe A21N) ‘Insertion or replacement of other nervous system central stimulation device’
571 (NordDRG Swe A22N) 'Insertion of intracranial or vagal nerve stimulator'

The DRG 570/A21N is only for MDC 01 (Neurology). DRG 571 is used for both MDC 01 and MDC 19 (Psychiatry).

The property 01S52 ‘Implantation of intracranial or vagal nerve stimulator’ is given to 3 codes (as in the original proposal):
AASG20 ‘Stereotactic intracranial implantation of electrodes ‘
AASW01 ‘Implantation of intracranial stimulation device’
ADSB00 ‘Implantation of vagus nerve stimulating device’

These interventions as all others with the property 01S51 retain also that property.

In the logic changes Sweden has forgot to change the new rule 401D060000 for DRG 570/A20N in MDC 1 to the new DRG A21N/570. This rule is needed for also for Sweden!

(In the technical changes of the proposal, edited by myself, ID’s had been changed instead of ORD’s as must be! Therefore the order was wrong, sorry!)

At the expert group the original proposal was accepted for all countries. Norway has later informed that there is no need for changes in NordDRG Nor.

To follow the decission of the Expert group meeting, the DRG 570 should be used for MDC 01 and MDC 19 in other versions than Swe and Nor. In Swe the new DRG 571 (A21N in NordDRG Swe) will be used both MDC 01 and MDC 19. The modified DRG 570 is to be used only for MDC 01. It is coded in NordDRG Swe A21N instead of A20N. The content will not change in Nor and only minimally in Fin and we have no information on Den/Est/Ice/Lat/. Therefore we will not change the DRG coding for 570 in versions Com/Den/Est/Fin/Ice/Lat/Nor.

Since the original DRG 570 (A20N) will be removed from the NordDRG Swe and since the content of the new and old DRG 570 are almost identical and the rules for A21N and A20N are identical, we will not create new logic rules for the NordDRG Swe. Instead in the DRGnames of NordDRG Swe the DRG 570 will be mapped to A21N. The result is according to the proposal from Sweden.
This change in DRGnames corrects also the mistake of rule 401D060000.

To avoid mistundestandings the new property name is shortened to 'Implantation of vagal nerve stimulator'. This is the only purpose of the three interventions in psychiatry.

#10 Updated by Mats Fernström about 1 month ago

Mats Fernström, NPK Sweden 2018-10-10 (Swe ID C711 & C741)
This comment is published both under case #580 and case #587.
It is right that the original proposal in case #580/C711 was somewhat changed because of the proposal in case #587/C741. The original proposal in case #580/C711 concerning outpatients is still valid but the proposal concerning inpatients is totally replaced by the proposal in case #587/C741. Since the cases are related it is OK to combine the technical changes into one file as Martti has done, but I think there is a misunderstanding and confusion. Here is an attempt to clarify what we suggested and how we want it to be in the final Swedish version for 2019:
• The very expensive cases in DRG A20N/570 ‘Insertion or replacement of nervous system central stimulation device’ , those with implantation of vagal or intracranial stimulators, shall be grouped to a new group, DRG A21N/571 ‘Insertion of intracranial or vagal nerve stimulator’. In Sweden we have a policy to change the DRG code if the content of a group is significantly altered and therefor DRG A20N/570 will be replaced by DRG A22N with the text ‘Insertion or replacement of other nervous system central stimulation device’. In the file Tiedoston Technical changes case #580 & #587 version 2.xlsx Martti has mixed up the Swedish DRG codes in the sheet “drgnames”.
• We proposed a new procedure property, 01S52 with the text “Implantation of intracranial or vagal nerve stimulator” leading to the new DRG A21N/571 ‘Insertion of intracranial or vagal nerve stimulator’. In the file Tiedoston Technical changes case #580 & #587 version 2.xlsx, Martti has renamed 01S52 to “Implantation of vagal nerve stimulator” but that is only half the truth because the codes AASG20 ‘Stereotactic intracranial implantation of electrodes’ and AASW01 ‘Implantation of intracranial stimulation device’ also have the property 01S52. Property texts are of course of no importance for the grouping but they should be as correct as possible for future understanding of the system.
• Vagal stimulation is an accepted method to treat not only epilepsy but also treatment-resistant depression and therefore we want rules for the new DRG A21N/571 ‘Insertion of intracranial or vagal nerve stimulator’ based on 01S52 both in the MDC 01 and MDC 19 areas and that is correctly described in the file Tiedoston Technical changes case #580 & #587 version 2.xlsx.
• For outpatients, DRG A20O/570O ‘Insertion or replacement of nervous system central stimulation device, short therapy’, there are too few cases to make a split that corresponds to the split of DRG A20N/570. The only thing that we propose for outpatients is a rule for MDC 19 cases leading to DRG A20O/570O and that is also correctly described in the file Tiedoston Technical changes case #580 & #587 version 2.xlsx.
• We noticed Marttis concern about combining psychiatric cases with neurological in the same DRGs but we think that a DRG with the text “Insertion of intracranial or vagal nerve stimulator” (for inpatients) or the text “Insertion or replacement of nervous system central stimulation device” (for outpatients) gives a much better description than a DRG with the text “O. r. procedure w principal diagnos of mental illness or abuse”.

We are satisfied with the rules in Drglogic for the groups A20O, A21N and A22N in the SOS version for 2019 PL. The rules in the NCC version for 2019 PL are also OK with the exception that the rule with ORD 419D0109901 can be deleted (se file Drglogic for A20O A21N A22N in SWE 2019 PL.xlsx).

#11 Updated by Martti Virtanen about 1 month ago

2018-10-10 Martti Virtanen
Just a rapid comment in a hurry. It seems not logical that the rule 419D0109901 is not included for inpatients as the same rule is included for outpatients.
I will look more on this as soon as I have time.

#12 Updated by Mats Fernström about 1 month ago

Mats Fernström, NPK Sweden 2018-10-10 (Swe ID C711)
It is not that illogical. The rule handles procedures with 01S51 but without 01S52, which means procedures that never are performed for psychiatric reasons, as far as I know. I therefore fear that the rule will be impossible in practice. But of course, if you insist, we can have the rule. Impossible rules will not make any harm.

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