Case #587

Split of DRG A20N (570) ‘Insertion or replacement of nervous system central stimulation device’

Added by Mats Fernström about 1 year ago. Updated about 1 month ago.

Status:AcceptedStart date:2018-02-13
Priority:MajorSpent time:-
Assignee:Mats Fernström
Category:-
Target version:Target version 2019
Initiator:Sweden Target year:2019
Case type:Major Owner / responsible:
MDC:MDC01 Old forum status:
Target Grouper:SWE

Description

Problem
This case is an extension of case #580 ‘Vagus nerve stimulation for depression’ and if accepted, the technical changes for inpatients in case #580 are replaced by the technical changes described here.
We are sorry that the case is published after the deadline for major proposals but we had to wait for a formal decision at the board of the Swedish Neurosurgical Society.
The Swedish Neurosurgical Society wants a split of DRG A20N ‘Implantation/byte av nervstimulator’ (former DRG 570 ‘Insertion or replacement of nervous system central stimulation device’) so that cases with implantation of vagus nerve stimulating device (ADB00/ADSB00) and intracranial stimulating devices (AAG20/AASG20 ‘Stereotactic intracranial implantation of electrodes’ and AAW01/AASW01 ‘Implantation of intracranial stimulation deviceare’) are grouped to a separate DRG. The motivation is that these cases are much more expensive than other cases in DRG A20N/570.
Analysis
NPK, Sweden – 2018-02-08

Swedish cost data is presented in Appendix C741.xlsx, sheet 1 and it shows an increasing number of cases in the suggested new DRG (224 cases in 2016) and they are approximately twice as expensive as others. The cases are only in university hospitals but unevenly distributed at them (Appendix C741.xlsx, sheet 2), which can further justify a split. The number of outpatient cases with the procedure codes at issue is so small (just four cases during 2016) that a split of DRG A20O/570O is not possible.
Suggestion
NPK, Sweden – 2018-02-08

DRG A20N ‘Implantation/byte av nervstimulator’ (former DRG 570 ‘Insertion or replacement of nervous system central stimulation device’) is divided so that cases with implantation of vagus nerve stimulating device (ADB00/ADSB00) and intracranial stimulating devices (AAG20/AASG20 ‘Stereotactic intracranial implantation of electrodes’ and AAW01/AASW01 ‘Implantation of intracranial stimulation deviceare’) are grouped to a separate DRG. In Sweden it will be DRG A21N ’Inläggning av intrakraniell och vagal nervstimuleringsutrustning’ and DRG A20N will be replaced by DRG A22N ‘Implantation/byte av annan nervstimuleringsutrustning’. (In Sweden we have a principle that DRG codes that are identical on a 3-digit level shall have the same medical content and therefor the code A20N cannot be retained since the content after the split doesn’t correspond to the outpatient group A20O.) In the common version we suggest that the new group is called DRG 571 ‘Insertion of intracranial or vagal nerve stimulator’ and that DRG 570 is renamed to ‘Insertion or replacement of other nervous system central stimulation device’.
To achieve the desired split we have to add a new procedure property (01S52 ‘Implantation of intracranial or vagal nerve stimulator’) to the procedure codes AAG20/AASG20, AAW01/AASW01 and ADB00/ADSB00 and insert new rules in Drglogic based on 01S52 leading to the new DRG. The first rule is for the Norwegian version and it is inserted in the pre-MDC area (like the existing rule for DRG 570) immediately before the present rule with ORD 400D900000 leading to DRG 570. (A question to Norway: Do you really want such a “strong” rule as a pre-MDC rule for DRG 570 ‘Insertion or replacement of nervous system central stimulation device’? If a more major procedure is performed during the same episode, you will still get DRG 570.) The second rule is for cases in MDC 01 and it is placed immediately before the present rule with ORD 401D059000. The third rule is for cases in MDC 19 mentioned in case #580 and it is inserted immediately before the present rule with ORD 419D011000. The fourth rule is for the post MDC area and it is inserted immediately before the present rule with ORD 490D010000. (This rule, like the rules for cases in MDC 01 and 19 will have no effect in the Norwegian version due to the existing rule with ORD 400D900000 that covers all MDCs).
See TC_C741.xlsx for details and note that these technical changes include and replace the changes for inpatients suggested in case #580 so if this case is accepted; the technical changes for inpatients described in #580 must not be done!
DRG change
Inpatient cases with the procedure codes AAG20/AASG20, AAW01/AASW01 or ADB00/ADSB00 that are allocated to DRG A20N/570 or DRG T01/424N in NordDRG 2018 will instead be allocated to the new DRG A21N/571. In the Swedish version, the remaining cases in DRG A20N will be grouped to DRG A22N and DRG A20N is deleted since the content doesn’t any longer correspond to the outpatient DRG A20O.
Technical change
Described above. See also TC_C741.xlsx for details.

Appendix C741.xlsx (16 KB) Mats Fernström, 2018-02-13 18:37

TC_C741.xlsx (23.9 KB) Mats Fernström, 2018-02-13 18:38

Technical changes case #580 & #587.xlsx (33.2 KB) Martti Virtanen, 2018-03-06 15:19

Drglogic for A20O A21N A22N in SWE 2019 PL.xlsx (11.3 KB) Mats Fernström, 2018-10-10 13:03

Technical changes case #580 & #587 version 2.xlsx (33.3 KB) Martti Virtanen, 2018-11-20 12:37

Case 587 - surgery in psychiatry.pptx (11.1 MB) Martti Virtanen, 2018-12-19 11:46

Decision #587_C741 SWE 2020.xlsx (13 KB) Mats Fernström, 2019-01-02 12:42

Tiedoston Technical changes case #580 & #587 version 2.1.xlsx (33.2 KB) Martti Virtanen, 2019-02-27 15:40

History

#1 Updated by Kristiina Kahur about 1 year ago

Finnish National DRG-Centre 15-2-2018

This case is also linked to #164 which suggested to create two new DRGs 570 and 570O.
In Finland, the number of cases in short therapy DRG 570O is bigger than in 570 (346 vs 270 cases in 2016).
Therefore, we included into analysis also the cases of short therapy DRG 570O.
The cost analysis shows that the cases with codes AAG20/AASG20, AAW01/AASW01 or ADB00/ADSB00 are remarkably more expensive compared to the rest of the cases in both DRGs.
In DRG 570O the total number of the cases with AAG20/AASG20, AAW01/AASW01 or ADB00/ADSB00 is 24 only which is relatively low. Another hand, the number of outpatient cases with abovementioned three codes has been increasing during 2014-2016 and it would make sense to have the same split also in DRG 570O. We come up with our final decision during the meeting.
Other than that the Finnish cost data support the split of current DRG 570 as suggested by Sweden

#2 Updated by Martti Virtanen about 1 year ago

2018-03-06 Martti Virtanen

This case clearly improves case #580.

Since this is really a combined 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.

#3 Updated by Mats Fernström 7 months ago

Mats Fernström, NPK Sweden 2018-10-10 (Swe ID C711 & C741)
This comment is published both under case #580 and case #587.

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 excep-tion that the rule with ORD 419D0109901 can be deleted (se file Drglogic for A20O A21N A22N in SWE 2019 PL.xlsx).

#4 Updated by Martti Virtanen 5 months ago

2018-11-17 Martti Virtanen
One more update to this case. To ease others following the discussion I will remove my previous comment as well as that of Matts and try to summarize the thing here.

There are two problems mixed in these cases (Case #570 and #587).

First the 'vagal nerve stimulation' by a device implanted in the body of the patient and the intracranial devices are clearly more expensive than interventions involving other implanted neural devices.

Second the Indication for their use are central nervous system problems including diseases that classified as neurological (MDC01) but also as psychiatric (MDC19). Depression treatment by vagal nerve stimulation is the most typical example of the latter.
In MDC 19
the case are now assigned to the unspecified DRG 424/424O 'O. r. procedure w principal diagnosis of mental illness' (T01N/T01O in Sweden) A more specific DRG, that would describe the resource use better, is needed.
Sweden proposed
originally that the patient cases with interventions involving these devices should be assigned to MDC 01 DRG 570/570O 'Insertion or replacement of nervous system central stimulation device' (A20N/A20O in Sweden) or to a new MDC 01 DRG 571 'Insertion of intracranial or vagal nerve stimulator' (A21N in Sweden) both with MDC01 and MDC19 principal diagnosis.

The interventions at issue are
AASG20 ‘Stereotactic intracranial implantation of electrodes’
AASW01 ‘Implantation of intracranial stimulation device’
ADSB00 ‘Implantation of vagus nerve stimulating device’

Current solution
The expert group meeting 2018 decided for all versions that a rule with 01S51 'Insertion or replacement of nervous system central stimulation device' will be included for MDC 19.
This by the rule 419D0109910 (sorry I had wrong id and ord in previous version).
In addition a rule for 01S52 was added both for outpatients and inpatients to postMDC rules.

This means that as inpatients the psychiatric patient cases (MDC 19) of this type will be assigned to DRG 424 (T01N). However, as outpatients they will be assigned to DRG 570 (A20O) that includes also the patients with Insertion vagal nerve stimulator (with property 01S52).

Patient cases with almost any other MDC (principal dx from other MDC's) as inpatients will be assigned by inpatient PostMDC rules to the DRG 570 or 571 (A20N/A21N)) depending which intervention was performed. As outpatients these patient cases with other MDC's will be assigned to DRG 570O (A20O) by an outpatient postMDC rule.

In Sweden the DRG A20N (570) is recoded to DRG A22N. Since the coding is not changed in the other versions, this is done by linking A22N to 570 (Drgnames for Sweden)

The results of grouping
Cases with interventions with property 01S52 will be assigned to:
in MDC 01 as outpatients to DRG 570O/A20O
in MDC 01 as inpatients to DRG 571/A22N
in MDC 19 as outpatients to DRG 571O/A21O
in MDC 19 as inpatients to DRG 571/A22N
in most other MDC's as outpatients to DRG 570O/A20O
in most other MDC's as inpatients to DRG 570/A21N

Cases with interventions with 01S51 but not with 01S52 will be assigned to:
in MDC 01 as outpatients to DRG 570O/A20O
in MDC 01 as inpatients to DRG 570/A21N
in MDC 19 as outpatients to DRG 424O/T01O
in MDC 19 as inpatients to DRG 571 (A21N) in other versions than Swe and to T01N (424) in NordDRG Swe
in most other MDC’s as outpatients to DRG 570O/A20O
in most other MDC’s as inpatients to DRG 570/A21N

Continued discussion
Sweden then correctly pointed out that although 01S52 can typically be performed for psychiatric patients, the other interventions with 01S51 are rare in MDC19 and therefore they should not be assigned to DRG 570 in MDC 19. However, Sweden has also detected a few cases with other 01S51 interventions in psychiatry.

Because of the first comments the rule 419D0109910 is now not included in SWE version but should be included in other versions. However Sweden is most probably going to introduce the rule in NordDRG Swe 2020.

Further discussion
Sweden intends to add the rule 419D0109910 in NordDRG 2020.
I think this item needs a thorough discussion next year. The matter is of minor importance because of quite low number of cases but needs a proper discussion for the principles.
Please note the attached PowerPoint presentation on the matter.

#5 Updated by Martti Virtanen 4 months ago

  • File deleted (Case 587 - surgery in psychiatry.pptx)

#6 Updated by Martti Virtanen 4 months ago

#7 Updated by Mats Fernström 4 months ago

Mats Fernström, NPK Sweden 2019-01-02 (Swe ID C741)
The three interventions
• AASG20 ‘Stereotactic intracranial implantation of electrodes’
• AASW01 ‘Implantation of intracranial stimulation device’
• ADSB00 ‘Implantation of vagus nerve stimulating device’
on inpatients are 103% more expensive than the rest of the interventions with 01S51 (see Appendix C741.xlsx) so that is why we, at the request of the Swedish Neurosurgical Society, wanted to place them in another group than DRG A20N/570 ‘Insertion or replacement of nervous system central stimulation device’. The new group in NordDRG 2019 for these three interventions is DRG A21N/571 'Insertion of intracranial or vagal nerve stimulator'. It was not possible to split DRG A20O/570O in a similar way because the number of outpatients with these three interventions is far too small.
It was also pointed out by the Swedish Neurosurgical Society that vagal nerve stimulation is not only used for neurological diseases like epilepsy. It is also an established method to treat severe depression so that is why we wanted MDC 19 cases to be included in DRG A21N/571 instead of being grouped to the unspecified DRG T01N/424 'O. r. procedure w principal diagnosis of mental illness'. The implantation procedures and the costs are the same irrespectively of the diagnoses and a separate group for MDC 19 cases should be too small. Even though MDC 19 cases are included, the number of outpatients is too small to create an outpatient group corresponding to DRG A21N/571.
Thus, in NordDRG 2019 SWE, DRG A20N/570 ‘Insertion or replacement of nervous system central stimulation device’ is replaced by DRG A21N/571 'Insertion of intracranial or vagal nerve stimulator' and DRG A22N/570 ‘Insertion or replacement of other nervous system central stimulation device’ but DRG A20O/570O is not divided.
MDC 19 cases are included in DRG A21N/571 and in DRG A20O/570O but in our original technical changes there was no rule for psychiatric inpatients leading to DRG 570/A22N. Martti has pointed out that this is illogical but we thought that there was no need for such a rule because we believed that the procedures at issue (those with 01S51 but without 01S52) are not indicated in psychiatry. This thought was somewhat wrong, however. In the Swedish national Patient Register (PAR 2016) there were 2 % of the cases in DRG T01N/424 'O. r. procedure w principal diagnosis of mental illness' with such a procedure. Thus, Sweden will insert the rule in our version for 2020. The rule will be placed immediately after the rule with ORD 419D0109900 which gives the ORD 419D0109901. The rule is a copy of that with ORD 419D0109900 except that 01S52 is replaced by 01S51 and DRG A21N is replaced by A22N. Se the file Decision #587_C741 SWE 2020.xlsx.
Martti seems to be concerned that we are mixing patients from MDC 01 and MDC 19 in the same group, but in this case we think it's OK. The current procedures are performed at the neurosurgical department and the costs are the same regardless of the diagnosis. In addition, if we split them by MDC, it would be too small groups.

#8 Updated by Kristin Dahlen 2 months ago

Just to make a remark on the Norwegian version. We do have patients from both MDC 01 and MDC 19 in the Norwegian version. In addition to this we have also implemented possibilities for patients from MDC 06, MDC 08 and MDC 11, as we for instance do have a relatively high number of patients with fecal or urinary incontinence where a central stimulation device is implanted.

#9 Updated by Kristiina Kahur 2 months ago

Finnish National DRG-Centre 2019-2-14

We agree with Martti that the matter is of minor importance because of quite low number of cases but needs a proper discussion for the principles. We also agree with Mats that in given situation (taken into account the cost data) it would be reasonable to mix MDC1 and MDC19 patients.
We support this change as proposed by Sweden.

#10 Updated by Martti Virtanen about 1 month ago

2019-02-27 NCC (MV)
We seem to agree about ther principals but I think that at the expert group meeting we will look at last slide of the attached PowerPoint presentation. That gives a theoretical basis for the decission.

The rule proposed by Sweden already exists (id 419D0109910) and shall not be recreated. Only /Swe has to be added to the nat_ver variable (See Technical changes 2.1)

#11 Updated by Martti Virtanen about 1 month ago

  • Status changed from Further active to Accepted

2019-03-11 Expert group
Expert group accepted the last addition (for Swe).

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