Rules to determine the side of the lens procedure
|Target version:||Target version 2019|
|Case type:||Owner / responsible:||National organisations|
|MDC:||MDC02||Old forum status:|
The case concerns the rules of DRG 039O Lens procedure, one-sided, short therapy and 039P Lens procedure, bilateral, short therapy.
The rules are pretty clear, depending on Z-code, the case groups whether to 039O (ZXXA05/ZXA05 left or ZXXA00/ZXA00 right) or 039P (ZXXA10/ZXA10 bilater, or combination of left+right).
The problem occurs while during the same contact another eye procedure is performed on both eyes, but the lens procedure is performed only on one eye.
E.g. During the contact patient is performed procedure CKFK20/CK2X4 Examination of eye with optical coherence tomography (OCT) on both eyes, and the code ZXA10 is used to indicate two sides. This procedure is followed by another (main) procedure CJSE20/CJE20 Phakoemulsification with implantation of artificial lens in posterior chamber, but this is performed only on left eye and the code ZXA05 is used to indicate it.
As a result, the case ends up in DRG 039P and not in DRG 039O which is not the expected result.
According to grouping rules, the sequence of procedure codes does not change the grouping, i.e. the code ZXXA10 Bilater is used for grouping regardless its position although it does not concern the lens procedure.
There is no economical analysis needed.
We cannot provide the suggestion yet how to solve the problem. It might be an easy one, we just have not figured it out. However, we would like to take this issue to the expertnetwork meeting to find a solution.
The cases with one or two-sides lens procedure should group to DRGs 039O or 039P, respectively.
#1 Updated by Mats Fernström over 2 years ago
Mats Fernström, NPK Sweden 2018-02-22
There is a similar problem with DRG F25O/162P ’Inguinal and femoral hernia procedures, bilateral, short therapy’ and DRG H00N/471N ’Bilateral or multiple major joint procs of extremitates’. I mentioned the problem already in Case 2007-MDC08-12 ’Bilateral non-surgical procedures may lead to DRG 471’. The example in that case was:
The patient is operated for a left sided hip fracture and a central venous catheter is inserted into the right subclavian vein. A correct procedure coding will then be:
NFB19 Primary partial prosthetic replacement of hip joint
ZXA05 Left side
TPH20 Insertion of central venous catheter …
ZXA00 Right side
The grouping result will wrongly be DRG 471 instead of the correct DRG 209A.
Then, in the years 2007-2008, we found very few cases that were incorrectly grouped in a similar way so the expert network saw no need to change the grouping logic. It could be interesting to do a new analysis, but we have no time to do it before the meeting in Iceland.
I cannot see any possibility to solve this problem within the present NordDRG logic, however, so I think that we have to make changes in the primary coding. Maybe adding subcodes meaning “bilateral” to all existing procedure codes that can be performed bilaterally or maybe code pairs similar to the asterisk dagger pairs for diagnoses?
#2 Updated by Kristin Dahlen over 2 years ago
We have faced the same problem also in Norway. For a permanent solution to the problem we are awaiting the possibility to register and report data with the procedures belonging together, bundled. We will then be able to see what examination or surgery the bilateral code belong to. As we cannot do this at the moment we have made a koding rule saying that the bilateral code, ZXA10, shall only be used for surgery. We are also aware of the fact that we will have to do changes in the DRG-logic or the surrounding systems to take care of this together with a change in the reporting system.
#3 Updated by Martti Virtanen over 2 years ago
2018-03-07 Martti Virtanen
This is true. WHO is suggesting a new model for ICD-11 dx coding where a cloud of several codes indicates one problem and patient can have several clouds that are marked in information system thus making it possible to know which codes belong together.
This wouod obviously allow for clever rules for the grouper. I supsect we cannot solve this problem now.