Need for apr drg rerouting logic within mdc

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Need for APR-DRG Rerouting Logic Within MDC Reroutings: This is the situation where the PDX provides sufficient information for MDC assignment but does not provide sufficient information for assignment to the most appropri- ate DRG. It also includes the situation where the OR procedure is unclear. For example: The PDX provides no information about the patient’s health status but the SDXs do. For example, the V3000–V3921 live newborn codes accurately describe the reason for admis- sion to the hospital (being born), but provide no information as to whether the neonate has any medical problems. To assign these patients to a meaningful APR-DRG, it is necessary to examine the SDXs for various possible problems and to create a hierarchy amongst these problems in the event the neonate has multiple problems.
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60 The PDX is imprecise but Age clarifies. For example, PDX aftercare not elsewhere classified and Age < 90 days clarifies that the admission is for neonatal aftercare. There is ambiguity in sequencing of PDX and SDX, but either way the same patient is being described. For example, PDX pneumonia and SDX cystic fibrosis. A symptom code has been missequenced as the PDX. For example, PDX chest pain and SDX angina pectoris or coronary atherosclerosis. The OR procedure is imprecise but the PDX clarifies. For example, bone ostectomy not else- where classified (includes vertebra) and PDX back/neck disorder clarifies that the patient would better be assigned to an APR-DRG for other back/neck procedures than other muscu- loskeletal procedures. Across MDC Reroutings: This is the situation where the PDX does not provide sufficient informa- tion for assignment to either the most appropriate MDC or APR-DRG. This includes many of the same PDX ambiguities as the Within MDC Reroutings except that the PDX ambiguity affects MDC assignment as well as APR-DRG assignment. For example: The PDX describes body system more broadly than the MDCs of the APR-DRG system. For example, PDX 9961 mechanical complication of other vascular devices (MDC 5) includes both peripheral vascular devices (MDC 5) and renal dialysis shunt (MDC 11). The PDX does not describe the specific body system manifestation. For example, PDX 25080–25083 diabetes with manifestations not elsewhere classified (MDC 10) includes mani- festations that affect other body systems—skin ulcer (MDC 9), bone involvement in other diseases (MDC 8), and osteomyelitis (MDC 8). The sequencing of PDX and SDX is ambiguous. For example, PDX hypovolemia (MDC 10) and SDX gastroenteritis (MDC 6). This is fundamentally a gastroenteritis patient with hypov- olemia (dehydration), which is common to patients hospitalized for gastroenteritis. A symptom code is missequenced as the PDX. For example, PDX fever (MDC 18) and SDX agranulocytosis/neutropenia (MDC 16). Another example is PDX pulmonary edema (MDC 4) and SDX congestive heart failure (MDC 5).
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  • Fall '18
  • Diagnosis-related group, DRGs

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