MS-DRGs Under ICD-10: A Look at the Draft MS-DRG
Mappings and CC Lists
Presented by:
Lynn-Marie Wozniak, MS, RHIT
April 25, 2013
Presentation Objectives
By the completion of this webinar participants will be able to do (or know)
the following:
• Review the process used to convert the MS-DRG Grouper from ICD-9-CM
to ICD-10-CM/PCS
• Access and navigate the V30.0 Draft MS-DRG Manual to find specific MSDRG criteria as well as MCC/CC lists, CC exclusions and surgical hierarchies.
• Recognize similarities and differences between the current MCC and CC
lists and the ICD-10-CM based lists
• Identify the affect that the ICD-10-CM/PCS codes and the code mappings
have on the assignment of cases to high volume MS-DRGs
• Determine which high-volume MS-DRGs will be most affected by the
transition to ICD-10-CM/PCS
CMS MS-DRG Conversion Project: I-9 to I-10
• Goal: to develop an ICD-10 MS-DRG grouper that produces
the same results as the ICD-9-CM MS-DRG grouper
• Same MS-DRG structure
• Same MS-DRGs
• Same surgical hierarchy
• Same MS-DRG definitions and criteria
• Replaced all the ICD-9-CM code lists with corresponding
ICD-10-CM/PCS lists
Process Used to Replace ICD-9-CM Code Lists with ICD-10CM/PCS Code Lists in MS-DRG Grouper
• Goal: Include all possible ICD-10-CM/PCS codes in the converted MS-DRG
Grouper
• ICD-10-CM/PCS codes that had a one-to-one mapping (GEMs) with an ICD-9-CM
code were mapped to the same DRG(s) as the ICD-9-CM code.
• ICD-10-CM/PCS codes that did not have any mapping back to ICD-9-CM (about 500
codes) had an ICD-9-CM code assigned to them for grouping purposes by the
experts involved in the conversion project
• ICD-10-CM/PCS codes that mapped to multiple ICD-9-CM codes that were assigned
to different DRGs had to be reviewed and decision made as to where best to put
them.
• If one of the ICD-9-CM codes was “dominant” by more than 20% in terms
frequency of occurrence, the ICD-10-CM/PCS code was mapped to it, if not,
• ICD-10-CM/PCS code assigned to the closest matching ICD-9-CM codes in
terms of definition and diagnoses classified to it.
ICD-10-CM to ICD-9-CM GEMS: Reverse Look-Up
Sample of I-10 to 1-9 GEMS : COPD Codes
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J40
J410
J411
J418
J42
J430
J431
J432
J438
J439
J439
J440
J440
J441
J441
J449
J449
J449
490 00000
4910 00000
4911 00000
4918 10000
4919 00000
4928 10000
4928 10000
4928 10000
4928 10000
4920 10000
4928 10000
49122 10000
49321 10000
49121 10000
49322 10000
49120 10000
49320 10000
496 10000
ICD-10CM
Codes
ICD-9CM
Codes
Mapping Example: MS-DRG 069 – Transient Ischemia
ICD-9-CM Codes
ICD-10-CM Codes
PRINCIPAL DIAGNOSIS
4350 Basilar artery syndrome
4351 Vertebral artery syndrome
4352 Subclavian artery syndrome
4353 Vertebrobasilar artery syndrome
4358 Transient cerebral ischemia, NEC
4359 Transient cerebral ischemia, NOS
4371 Acute cerebrovascular insufficiency
PRINCIPAL DIAGNOSIS
G450 Vertebro-basilar artery syndrome
G451 Carotid artery syndrome (hemispheric)
G452 Multiple and bilateral precerebral artery syndromes
G458 Other transient cerebral ischemic attacks and related syndromes
G459 Transient cerebral ischemic attack, unspecified
G460 Middle cerebral artery syndrome
G461 Anterior cerebral artery syndrome
G462 Posterior cerebral artery syndrome
I6781 Acute cerebrovascular insufficiency
I6782 Cerebral ischemia
I67841 Reversible cerebrovascular vasoconstriction syndrome
I67848 Other cerebrovascular vasospasm and vasoconstriction
I6789 Other cerebrovascular disease
The ICD-10-CM principal diagnosis codes classified to MS-DRG 069 consist of all the
ICD-10-CM codes in the GEMs that are mapped to the ICD-9-CM principal diagnosis
codes in first column.
ICD-10-CM Codes That Do Not Map to any ICD-9-CM Code
The experts involved in the conversion project mapped the ICD-10-CM codes
that were not included in the GEMs to ICD-9-CM codes, MDCs and MS-DRGs.
ICD-10-CM
ICD-9-CM
MDC and MS-DRG
G43.2, Status migrainosus
346.92, Migraine, unspecifed, without
mention of intractable migraine with status
migrainosus
MDC 1
Headaches (MS-DRGs102-103)
T36-50**6*, Underdosing (489
codes),
V58.69, Long-term (current) use of other
medications
MDC 23
Aftercare (MS-DRGs 949-950)
Z66, Do not resusictate
V68.89, Encounters for other specified
administrative purpose
MDC 23
Other Factors Influencing Health
Status (MS-DRG 951)
Z67*, Blood type (10 codes)
V68.89, Encounters for other specified
administrative purpose
MDC 23
Other Factors Influencing Health
Status ( MS-DRG 951)
CMS.gov/Medicare/Coding/ICD-10-MS-DRG Conversion Project.html:
Converting MS-DRGs 26.0 to ICD-10-CM and ICD-10-PCS – Updated 2/25/13 with new impact article [Zip.612KB]
Mapping Example: ICD-10-CM Code Mapped to More Than One ICD9-CM Code
ICD-10-CM Code
ICD-9-CM Codes
MS-DRG List
FY 2007 MedPAR
Records
K22.8 Other specified
diseases of esophagus
Includes: Hemorrhage
of esophagus NOS
530.82 Esophageal
hemorrhage
Major Esophageal
Disorders (MS-DRGs
368-370)
10,167
K22.8 Other specified
diseases of esophagus
Includes: Hemorrhage
of esophagus NOS
530.89 Other diseases
of esophagus
Esophagitis,
Gastroenteritis and
Miscellaneous Digestive
Disorders (MS-DRGs
391-392)
8,685
CMS.gov/Medicare/Coding/ICD-10-MS-DRG Conversion Project.html:
Converting MS-DRGs 26.0 to ICD-10-CM and ICD-10-PCS – Updated 2/25/13 with new impact article [Zip.612KB]
ICD-10-CM to ICD-9-CM GEMS: Reverse Look-Up
Sample of I-10 to 1-9 GEMS : COPD Codes
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J40
J410
J411
J418
J42
J430
J431
J432
J438
J439
J439
J440
J440
J441
J441
J449
J449
J449
490 00000
4910 00000
4911 00000
4918 10000
4919 00000
4928 10000
4928 10000
4928 10000
4928 10000
4920 10000
4928 10000
49122 10000
49321 10000
49121 10000
49322 10000
49120 10000
49320 10000
496 10000
Sample of Reimbursement
GEMS: COPD Codes
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J40
J410
J411
J418
J42
J430
J431
J432
J438
J439
J440
J441
J449
1 490
1 4910
1 4911
1 4918
1 4919
1 4928
1 4928
1 4928
1 4928
1 4928
1 49122
1 49121
1 496
Special Challenges Involving Mapping ICD-10-PCS Codes to ICD9-CM in MS-DRG Grouper – Many to One
• Multiple ICD-10-PCS codes mapped to a single ICD-9-CM procedure code due to
ICD-10-PCS having a separate version of a code for each body system/body part,
and ICD-9-CM having only one code that does not specify body part
• In ICD-9-CM the single code is classified to multiple MS-DRGs. In ICD-10-PCS the
codes were distributed among the MS-DRGs based on body system/body part in
the code.
• Example
– 92.27, Implantation or insertion of radioactive elements (1 code, in 12 MDCs, 35 MSDRGs)
– 0xHxx1Z, Root operation is Insertion, and the device is Radioactive Element and there is
no qualifier, but the body system, body part and approach changeable. This equals
dozens of codes.
• Project experts assigned the specific ICD-10-PCS implantation or insertion of
radioactive element codes to the 12 MDCs and 35 MS- DRGs on the basis of the
body system/part involved, matching it to each MDC and then the MS-DRGs within
the MDC.
Special Challenges Involving Mapping ICD-10-PCS Codes to ICD9-CM in MS-DRG Grouper – MDC Body System Map
CMS.gov/Medicare/Coding/ICD-10-MS-DRG Conversion Project.html:
Converting MS-DRGs 26.0 to ICD-10-CM and ICD-10-PCS – Updated 2/25/13 with new impact article [Zip.612KB] APPENDIX B
Special Challenges Involving Mapping ICD-10-PCS Codes to ICD9-CM in MS-DRG Grouper – One to Many
• For ICD-10 codes that translate to multiple single ICD-9 codes
in the GEMs, one ICD-9 code was selected for reimbursement
purposes.
• For ICD-10 codes that translate to multiple ICD-9 clusters in
the GEMs, one ICD-9 cluster was selected for reimbursement
purposes.
– The mapping of one ICD-10 may require as many as six ICD-9 codes to
reproduce the meaning of the ICD-10 code. In such cases, where an
ICD-10 code maps to an ICD-9 cluster, all the codes in the cluster were
included.
Examples of ICD-10-PCS Mapped to ICD-9-CM Code Clusters
Converting the CC and MCC Lists from ICD-9-CM to ICD-10-CM
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Start with ICD-10-CM to ICD-9-CM GEMS
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Flag all the ICD-9-CM codes on the GEMS that
are on the CC or MCC list
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Select all the ICD-10-CM codes that are mapped
to an ICD-9-CM CC and MCC code for the ICD10-CM CC and MCC List.
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If map to multiple CC codes  it is a CC
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If map to multiple MCC codes  it is a MCC
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If map to a CC and an MCC, or a CC and a nonCC, then dominant code was picked. If no
dominant code, expert panel picked.
ICD-10-CM
Codes
(Put all the
codes that are
mapped to ICD9-CM CCs or
MCCs on the CC
or MCC list)
ICD-9-CM Codes
(flag all the
codes on the CC
and MCC list)
Results of CC and MCC List Conversions
Conversion Summary
MCC
CC
Total
ICD-9-CM CCs and MCCs on List
1,592
3,427
5,019
ICD-10-CM Codes Auto-translated
3,152
13,594
16,845
ICD-10-CM List Conflicts
99
(82 resolved based on
frequency; 17 resolved by
expert panel)
ICD-9-CM CCs and MCCs with no
corresponding ICD-10-CM Codes
43
55
98
(examples: Uncontrolled diabetes codes, GI
ulcers with obstructions, Multiple unspecified
injury codes)
CMS.gov/Medicare/Coding/ICD-10-MS-DRG Conversion Project.html:
Converting MS-DRGs 26.0 to ICD-10-CM and ICD-10-PCS – Updated 2/25/13 with new impact article [Zip.612KB]
Principal Diagnosis is Its Own CC
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Cytomegaloviral hepatitis
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Sickle-cell disease with acute chest syndrome
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Diabetes mellitus with diabetic peripheral
angiopathy with gangrene
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Atherosclerotic heart disease with unstable angina
pectoris
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Atherosclerosis of leg(s) with ulceration/gangrene •
of thigh/calf/ankle/foot/other/unspecified site
Raynaud's syndrome with gangrene
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Crohn's disease with intestinal
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obstruction/fistula/abscess
Colitis(ulcerative) (chronic) (pan) (left-sided) with •
intestinal obstruction/fistula/abscess
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Inflammatory polyps of colon with intestinal
obstruction/fistula/abscess
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Diverticulitis of small/large intestine with
perforation and abscess w/ or w/o bleeding
Calculus of bile duct with (acute) (chronic)
cholangitis, with or without obstruction
Reiter's disease (specify site(s))
Rheumatoid myopathy with rheumatoid arthritis
(specify site(s))
Endocarditis/pericarditis in systemic lupus
erythematosus
Dermatopolymyositis/polymyositis with myopathy
Systemic sclerosis with lung involvement/
myopathy
Sicca syndrome with myopathy
Osteonecrosis in diseases classified elsewhere
(specify site(s))
Chronic obstructive pyelonephritis
Gestational edema with proteinuria (specify
trimester)
Encounter for aftercare following transplant
(specify organ(s))
Principal Diagnosis is Its Own MCC
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Anthrax, candidal, erysipelothrix, gonococcal or listerial sepsis
Whooping cough due to Bordetella pertussis/parapertussis/other Bordetella species
with pneumonia
Cytomegaloviral pneumonitis or pancreatitis
Invasive pulmonary aspergillosis
Cerebral cryptococcosis
Ascariasis pneumonia
Septic/saddle/other pulmonary embolism with acute cor pulmonale
Alcoholic hepatic failure with coma
Toxic liver disease with hepatic necrosis, with coma
Acute and subacute, or chronic hepatic failure with coma
Pressure ulcer (specify site), stage 3 or stage 4
Severe sepsis with septic shock
Traumatic cerebral edema without loss of consciousness, initial encounter
Traumatic cerebral edema with loss of consciousness, (specify time), initial encounter
Other Issues That Had to be Resolved During Conversion
• Mapped 1st, 2nd and 3rd
trimester OBcodes to
antepartum codes with 5th digit
‘3’.
• Mapped delivery codes to OB
codes with 5th digit “2”, and
post-partum to OB codes with
5th digit “4”
• Mapped subsequent and
sequela encounter codes to
Aftercare and Late effect codes
OB Codes
• Antepartum codes
• Delivery codes
• Postpartum codes
• Aftercare codes
Subsequent • Late effect codes
and Sequela
Example of Other Issues: MS-DRGs 466-468, Revision of Hip
and Knee Replacement
• Joint revision procedure codes mapped to ICD-9-CM codes in
three different MS-DRGs
• Required combinations of ICD-10-CM codes to get cases to go
to revision MS-DRGs 466-468.
• Example:
– 0SR90J5 Replacement of Right Hip Joint with Synthetic Substitute,
Metal on Polyethylene, Open Approach
– And
– 0SP90JZ, Removal of Synthetic Substitute from Right Hip Joint, Open
Approach
Example of Other Issues: MS-DRGs 466-468 (partial list)
CMS.gov Website
CMS.gov/Medicare
CMS.gov/Medicare ICD-10 link
CMS.gov/Medicare/ICD-10
CMS.gov/Medicare/ICD-10/GEMS
CMS.gov/Medicare/ICD-10/Conversion Project
CMS.gov/Medicare/ICD-10/Conversion Project
MS-DRG Manual Table of Contents
Index to MS-DRGs
MS-DRG 069: Transient Ischemia
MS-DRG Manual Table of Contents
MDC 4: MS-DRG Chart
MS-DRGs 207 and 208 Code Lists and Grouper Logic
MS-DRG Manual Table of Contents
Appendix A: List of MS-DRGs
Appendix B: Diagnosis Code/MDC/MS-DRG Index
Appendix C: CC and MCC Exclusion List
Appendix C: Pop-up Exclusion List
Appendix D: Surgical Hierarchy
MDC 06,Diseases & Disorders of the Digestive System
Surgical Hierarchy
MS-DRGs
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326-328
329-331
332-334
335-337
338-343
344-346
347-349
350-355
356-358
Stomach, Esophageal and Duodenal Procedures
Major Small and Large Bowel Procedures
Rectal Resection
Peritoneal Adhesiolysis
Appendectomy
Minor Small and Large Bowel Procedures
Anal and Stomal Procedures
Hernia Procedures
Other Digestive System O.R. Procedures
Appendix E: Operating Room Procedures and Procedure
Code/MS-DRG Index
Tables of Procedure Code Combinations Required for Specific
MS-DRGS
• Pacemaker Lead/Device Reference Table
• Cardioverter-Defibrillator Lead(s)/Generator Reference Table
• Kidney/Pancreas Transplant Reference Table
• Intracardiac Lead/Device Reference Table
• Heart Assist System Table
• Major Brain Device Implant Table
• Neurotransmitter/Neurostimulator Table
Appendix E: Intracardiac Lead Table
Appendix E: O.R. Procedures and Procedure Code/MS-DRG
Index
OHB8XZZ, Excision, Skin, Buttocks
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0HB8XZZ
01
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0HB8XZZ
0HB8XZZ
0HB8XZZ
0HB8XZZ
0HB8XZZ
0HB8XZZ
0HB8XZZ
02
03
04
05
06
07
08
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0HB8XZZ
0HB8XZZ
09
10
570-572
622-624
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0HB8XZZ
0HB8XZZ
0HB8XZZ
0HB8XZZ
0HB8XZZ
0HB8XZZ
0HB8XZZ
0HB8XZZ
11
12
13
16
21
22
22
24
673-675
715-718
749-750
802-804
901-903
927
928-929
957-959
040-042
133-134
166-168
356-358
423-425
463-465
Peripheral and Cranial Nerve and Other Nervous System
Procedures
Extraocular Procedures Except Orbit
Other Ear, Nose, Mouth and Throat O.R. Procedures
Other Respiratory System O.R. Procedures
Other Circulatory O.R. Procedures
Other Digestive System O.R. Procedures
Other Hepatobiliary or Pancreas O.R. Procedures
Wound Debridement and Skin Graft Except Hand, for
Musculoskeletal and Connective Tissue Disorders
Skin Debridement
Skin Grafts and Wound Debridement for Endocrine, Nutritional
and Metabolic Disorders
Other Kidney and Urinary Tract Procedures
Other Male Reproductive System O.R. Procedures
Other Female Reproductive System O.R. Procedures
Other O.R. Procedures of the Blood and Blood Forming Organs
Wound Debridements for Injuries
Extensive Burns or Full Thickness Burns with MV 96+Hours
Full Thickness Burns
Other O.R. Procedures for Multiple Significant Trauma
MS-DRG Manual Table of Contents
Appendix I: Hospital Acquired Conditions (HACS) List
Impact of MS-DRG Conversion to ICD-10-CM/PCS on DRG
Assignment
Recoded FY2010 MedPAR data into ICD-10-CM/PCS using GEMS
and many project specific rules to ensure correctness of code
mapping and regrouped them using v30.0 ICD-10 MS-DRG
Grouper
• 99% of cases assigned to same MS-DRG
• 1% of cases assigned to a different MS-DRG
– 45% to higher weighted MS-DRGs
• 75% of shifts to higher weighted MS-DRGs due to gaining a CC or MCC
– 55% to lower weighted MS-DRGs
• 40% of shifts to lower weighted MS-DRGs due to losing a CC or MCC
Top MS-DRGs with Positive Shifts
DRG
Reason for Shift
011, Tracheostomy for
face, mouth and neck dx
w/ MCC
Tracheostomy coded separately from radical larngectomy in ICD-10CM so more cases with MCC moving into Trach MS-DRGs
037, Extracranial
procedures w MCC
Shift of more cases into MS-DRG because of changes in MCC exclusion
lists.
066, Intracranial
hemorrhage or cerebral
infarction w/o CC/MCC
Cases shifted out of the w/o CC or MCC to higher weighted MS-DRGs
with CCs. Mostly cases with multiple CVA codes including CVAs that
mapped to ICD-9-CM code 433.81 which is not excluded as a CC with
other CVA codes.
812, Red blood cell
disorders w/MCC
ICD-10-CM coding guidelines put malignancy first and anemia second.
MS-DRG lost cases to other higher weighted cancer MS-DRGs
Top MS-DRGs with Negative Shifts
MS-DRG
Reason for Shift
981, Extensive O.R. procedures
unrelated to PDX with MCC
Most of the shifting is due to loss of an MCC
391, Esophagitis, gastroenteritis &
misc. digestive disorders with MCC
About 90% of the weight change is due to ICD-10-CM code K22.8, Other
diseases of esophagus being mapped to 530.89 in the reimbursement
mapping. It goes to a lower weighted MS-DRG.
885, Psychoses
296.20, Major depression is mapped to F32.9 which is classified to lower
weighted MS-DRG 881.
191, COPD with CC
Due to reclassification of COPD and asthma codes and the new combinations
not counting as CCs for each other as often.
974, HIV with major related condition
with MCC
In ICD-10-CM sepsis codes in category A41, but mapped to 995.51 which is
excluded as MCC for MS-DRG 974.
292, Heart failure and shock with CC
All cases with CC “Malignant hypertension, mapped to I10, Essential
hypertension which is not a CC.
References
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Mills, R.E., Butler, R.R., Averill, R.F., McCullough, E.C., Bao, M.Z., Impact of the Transition to ICD-10 on
Medicare Inpatient Hospital Payments. 3M Health Information Systems, Wallingford CT.
Mills, Ron. Estimating the Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments.
Center for Medicare and Medicaid Services, Agenda: ICD-9-CM Coordination and Maintenance Committee,
March 5, 2013. Accessed: April 23, 2013
http://cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/meetings.html
Centers for Medicare and Medicaid Services: Draft ICD-10-CM/PCS DRGv30 definitions manual. Modified :
February 13, 2013. Accessed: April 23, 2013 http://www.cms.gov/icd10manual/version30-fullcodecms/P0001.html
Converting MS-DRGs 26.0 to ICD-10-CM and ICD-10-PCS – Updated 2/25/13 with new impact article.
Accessed: April 23, 2013 http://cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-ConversionProject.html
2013 General Equivalence Mappings – Diagnosis Codes and Guide. Accessed: April 23, 2013.
http://cms.gov/Medicare/Coding/ICD10/2013-ICD-10-CM-and-GEMs.html
2013 General Equivalence Mappings – Procedure Codes and Guide. Accessed: April 23, 2013.
http://cms.gov/Medicare/Coding/ICD10/2013-ICD-10-PCS-GEMs.html
2013 Reimbursement Mappings – Diagnosis Codes and Guide. Accessed: April 23, 2013.
http://cms.gov/Medicare/Coding/ICD10/2013-ICD-10-CM-and-GEMs.html
2013 Reimbursement Mappings – Procedure Codes and Guide. Accessed: April 23, 2013.
http://cms.gov/Medicare/Coding/ICD10/2013-ICD-10-PCS-GEMs.html
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