CDI AND CODING GAP ANALYSIS - CDI Works

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MS-DRG, APR-DRG and IR-DRG Examples

Case	DRG SYSTEM	Hospital DRG & Relative Weight		Hospital DRG SOI/ROM	cdiWorks DRG & Relative Weight		cdiWorks DRG SOI/ROM	Comments
1	APR-DRG	004-3	10.0706	3/3	004-4	6.5399	4/3	Queries were generated for 2 secondary diagnoses in a patient with tracheostomy procedure. Secondary diagnoses were captured and shifted APR-DRG from 004-3 (SOI 3) to 004-4 (SOI 4).
2	APR-DRG	720-4	3.2003	4/3	710-4	6.3204	4/4	Query was generated for procedure in patient with sepsis. Documentation of procedure was clarified. This changed medical APR-DRG 720-4 to surgical APR-DRG 710-4.
3	APR-DRG	221-3	3.2113	3/3	221-4	6.5399	4/3	Appeal letter was submitted for a secondary diagnosis that was deleted by third party payer. Based on clinical indicators in the appeal letter, the decision by third party payer was overturned and shifted APR-DRG from 221-3 (SOI 3) to 221-4 (SOI 4).
4	APR-DRG	720-4	3.2003	4/3	130-4	6.0728	4/4	Coding change was made to assign pneumonia as principal diagnosis and sepsis as secondary diagnosis because clinical indicators did not support sepsis being present on admission. This changed APR-DRG from 720-4 to 130-4.
5	MS-DRG	871	1.8564	3/3	853	5.0571	3/3	Query was generated to clarify depth of debridement of pressure injury. Documentation of procedure was clarified. This changed medical MS-DRG 871 to surgical MS-DRG 853.
6	MS-DRG	682	1.4843	4/4	207	5.4845	3/3	Query was generated to clarify if pneumonia was reason for admission. Patient presented with acute kidney injury, chronic respiratory failure and was on mechanical ventilation. Pneumonia was captured as principal diagnosis, which changed MS-DRG from 682 to 207.
7	MS-DRG	908	1.9928	1/2	907	4.2161	4/4	Coding changes were made to capture acute septic encephalopathy, acute respiratory failure and pneumonia. These secondary diagnoses shifted MS-DRG from 908 to 907.
8	MS-DRG	812	0.8828	2/4	871	1.8564	3/3	Queries were generated for sepsis and acute septic encephalopathy. Principal diagnosis of sepsis and secondary diagnosis of acute septic encephalopathy were captured, which changed MS-DRG from 812 to 871.

IR-DRG Examples

Case	DRG SYSTEM	Hospital DRG & Relative Weight		Hospital DRG SOI/ROM	Hospital LOS	cdiWorks DRG & Relative Weight		cdiWorks DRG SOI/ROM	CDIworks LOS	Comments
1	IR-DRG	081601	1.2732	1/1	11	081603	4.9866	3/3	7	Query was generated for acute kidney injury, which shifted IR-DRG from 081601 (SOI 1/ROM 1) to 081603 (SOI 3/ROM 3).Patient was stabilized and should have been discharged on day 7, instead of day 11.
2	IR-DRG	044181	0.3366	1/1	7	044112	2.0041	2/1	5	Query was generated for acute respiratory failure, which changed IR-DRG from 044181 (SOI 1) to 044112 (SOI 2). Patient was stabilized and should have been discharged on day 5, instead of day 7.
3	IR-DRG	014141	0.7984	1/2	10	014142	1.3175	2/2	4	Coding Change was made to capture type 2 diabetes mellitus with hyperglycemia, which shifted IR-DRG from 014141 (SOI 1) to 014142 (SOI 2). Patient was stabilized and should have been discharged on day 4, instead of day 10.
4	IR-DRG	014141	0.7984	1/1	7	014143	3.565	3/2	7	Query was generated for cerebral vasculitis, which shifted IR-DRG from 014141 (SOI 1/ROM 1) to 014143 (SOI 3/ROM 2).
5	IR-DRG	051201	1.9627	1/1	2	051202	2.7972	2/1	2	Coding change was made to capture hemiplegia, which shifted IR-DRG from 051201 (SOI 1) to 051202 (SOI 2).
6	IR-DRG	064171	0.2674	1/1	23	064172	0.3780	2/1	11	Query was generated for hypotension, which shifted IR-DRG from 064171 (SOI 1) to 064172 (SOI 2). Patient was stabilized and should have been discharged on day 11, instead of day 23.
7	IR-DRG	061131	0.6951	1/1	4	061111	1.5054	1/1	4	Coding change was made to capture peritoneal adhesions and laparoscopy, surgical, enterolysis. These codes changed IR-DRG from 061131 to 061111.
8	IR-DRG	084182	1.1483	2/1	10	084183	2.1138	3/3	10	Coding change was made to capture acute encephalopathy, which shifted IR-DRG from 084182 (SOI 2) to 084183 (SOI 3).