Conditions that Impact MS-DRG Assignment for Newborns

Birth weight is used by APR-DRGs and MS-DRGs, and it impacts the assigned group.  

The topic of newborns is rarely addressed when we talk about coding or clinical documentation integrity. Birth weight, prematurity, extreme prematurity, and other significant problems are all conditions that impact the MS-DRG assignment.

Newborns are assigned to MS-DRGs in Major Diagnostic Category (MDC) 15. An interesting fact regarding this MDC is that there is not a surgical division for it. Here are some important definitions that impact the MS-DRG assignment:

• Neonate – an infant less than four weeks old
• Prematurity – the birth weight of 1,000-2,499 grams, or gestational age of 27-36 completed weeks of gestation
• Extreme prematurity – birth weight less than or equal to 999 grams, or gestational age of 23-26 completed weeks of gestation

The diagnosis codes on the newborn’s episode of care should begin with “P,” which would indicate a perinatal condition. It is important to be aware that not all diagnosis codes assigned to the newborn begin with “P,” as there are some “regular” codes that can be assigned as well. The diagnosis codes that begin with “O” can only be assigned to the mother’s episode of care. An edit will display if the codes are used incorrectly.

The above definitions relate to a coding perspective. The diagnoses of prematurity are assigned to MS-DRGs 791 and 792, depending on the presence of major problems. The diagnosis of extreme prematurity is assigned to MS-DRG 790.

Major problem diagnoses may also impact Full Term Neonates (MS-DRG 793) or Neonate (MS-DRG 794) codes. Examples of major problems include maternal conditions affecting the newborn; birth injuries; metabolic disturbances of the newborn; adverse effects of drugs; Rh or ABO incompatibility, and some congenital deformities.

Some code examples of the aforementioned categories are P07.14 (other low birth weight newborn, 1,000-1,249 grams); T50.4X5A (Adverse effect of appetite depressants, initial encounter); P36.4 (Sepsis of newborn due to Escherichia coli); P10.0 (Subdural hemorrhage due to birth injury); and P74.21 (Hypernatremia of newborn).

Conditions such as observation and evaluation of newborns for suspected conditions do not impact the MS-DRG assignment (see category Z05). Normal newborns are grouped by the principal diagnosis, which is most frequently found in category Z38. Some conditions that may be expected to impact the MS-DRG grouping are newborns affected by a prolapsed cord, newborns being light for gestational age, and extreme immaturity of a newborn of unspecified weeks of gestation. The unspecified information identifies a need for clinical documentation integrity.

From a clinical documentation integrity perspective, the newborn record should specify if the infant was born in the hospital or outside the hospital; congenital versus acquired conditions; gestational age; and birth injuries. Birth injuries can affect all body systems, so the specific body system and the extent of the injury are important in assigning the correct diagnosis code.

Remember that birth weight is used by APR-DRGs and MS-DRGs, and it impacts the assigned group. The specific codes can be found in the MS-DRG Definitions Manual, version 37, available online at https://www.cms.gov/icd10m/version37-fullcode-cms/fullcode_cms/P0017.html .

Programming Note:

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