Specificity in Getting Ms Drg Assignment Just Right

Specificity in Getting MS-DRG Assignment Just Right

I wanted to write today about the Coding Clinic from the American Hospital Association for the third quarter of 2020 – specifically, pages 28-29, titled “Right middle cerebral artery infarction and bilateral carotid artery occlusion,” which has a question about coding the diagnosis. The provider documented that the right carotid artery stenotic plaque caused the right middle cerebral artery infarction.

The Coding Clinic response was to code the cerebral artery infarction due to right carotid artery stenosis/occlusion. The stenosis/occlusion of the left carotid artery should also be coded.

I found this advice very helpful when reviewing payor denials. If a coder assigns a diagnosis code for the infarction of the right middle artery (I63.511), in addition to the infarction of the right carotid artery (I63.231), then it is labeled inappropriate if the Medicare Severity Diagnosis-Related Group (MS-DRG) assigned is MS-DRG 64 (Intracranial hemorrhage or cerebral infarction with MCC). The second infarction code adds a Major Complication/Comorbid Condition (MCC). As I talked to other coders, I found that they were unaware of this Coding Clinic guidance.

The financial impact is not insignificant. Assuming a facility blended rate of $5,000, the reimbursement for MS-DRGs 64 through 66 is shown in the table below:

MS-DRGDescriptionRelative WeightReimbursement
64Intracranial hemorrhage or cerebral infarction w/MCC2.003$10,015.00
65Intracranial hemorrhage or cerebral infarction w/CC1.0164$5,082.00
66Intracranial hemorrhage or cerebral infarction w/o MCC/CC0.6875$3,437.50

The reimbursement swing is more than $6,500 for each case that is incorrectly coded.

My goal in talking about this Coding Clinic citation is to make you aware of its existence and for coders to be proactive and avoid assigning two stroke codes where only one is needed. It is important to also assign codes for the occlusions. Proactivity will avoid needless payor denials. I also think that there may be opportunities for physician queries and/or education. The physician should document, if possible, which occlusion/stenosis is responsible for the patient’s stroke.

Inpatient coding and MS-DRG optimization are like the tale of Goldilocks. It should be just right where the hospital gets the exact reimbursement that it deserves for treating the patient.

Facebook
Twitter
LinkedIn

Related Stories

Transparency in Coverage Final Rule

Transparency in Coverage Final Rule

The healthcare industry’s landscape shifted dramatically with the implementation of the Transparency in Coverage (TiC) Final Rule. For compliance professionals navigating this regulatory terrain, understanding

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

2026 IPPS Masterclass 3: Master MS-DRG Shifts and NTAPs

2026 IPPS Masterclass Day 3: MS-DRG Shifts and NTAPs

This third session in our 2026 IPPS Masterclass will feature a review of FY26 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 14, 2025
2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

This second session in our 2026 IPPS Masterclass will feature a review the FY26 changes to ICD-10-PCS codes. This information will be presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 13, 2025
2026 IPPS Masterclass 1: Master ICD-10-CM Changes

2026 IPPS Masterclass Day 1: Master ICD-10-CM Changes

This first session in our 2026 IPPS Masterclass will feature an in-depth explanation of FY26 changes to ICD-10-CM codes and guidelines, CCs/MCCs, and revisions to the MCE, presented by presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 12, 2025

Trending News

Featured Webcasts

The Two-Midnight Rule: New Challenges, Proven Strategies

The Two-Midnight Rule: New Challenges, Proven Strategies

RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.

June 19, 2025
Open Door Forum Webcast Series

Open Door Forum Webcast Series

Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.

June 11, 2025
Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Substance abuse is everywhere. It’s a complicated diagnosis with wide-ranging implications well beyond acute care. The face of addiction continues to change so it’s important to remember not just the addict but the spectrum of extended victims and the other social determinants and legal ramifications. Join John K. Hall, MD, JD, MBA, FCLM, FRCPC, for a critical Q&A on navigating substance abuse in 2025.  Register today and be a part of the conversation!

July 16, 2025

Trending News

Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more

Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24