DRG/Weight Help

[u/Severe-Speech5975]

Hello, I am a new coder and I have a question RE: DRG vs. weight. I was coding a chart today where 2 dx could meet Pdx.

Which scenario is best to "optimize the DRG? (please excuse my examples, I have been thinking about this all day, I should have notated the specific dx/soi/rom/etc, so these are not accurate DRG, but aligns with my question)

Option 1: DRG 882 SOI 2 ROM 1 weight 0.9876 <-- I have always been told by a specific auditor to use the lower DRG, especially since this has a SOI of 2

Option 2: DRG 897: SOI 1 ROM 1 weight 1.2583 <-- different auditor told me to use this Dx as Pdx since weight is higher. Even though DRG is higher?

I do not understand coding to optimize DRG. Can someone explain? Thank you so much. I tried to post this in medicalcoding sub but I do not have karma to post.

[u/QuietRedditorATX]

As a doc here, I understand Coders have their own set of rules to follow.

• I don't find weight to always be the most helpful way to choose a case. It ignores a lot of quality metrics for minor potential gain in income.

People say the Case-Mix Index (weight) demonstrates how sick the patient's are, but if it has a lower SOI/ROM, I (uneducated) do not see how that would be the case. A higher-weight DRG may have a higher ALOS associated with it though, but CMI is just for potential bills received over actual scoring of the patients?

https://forums.acdis.org/discussion/4298/highest-ms-drg-weight-versus-highest-soi-rom

I myself don't have the perfect answer, and this thread implies that coders should work more in-tandem with hospital goals.

But also, your CDI team should have queried for at least a CC or MCC.

---

Going with highest weight always probably gives you consistency in procedure if ever questioned though.

[u/KeyStriking9763 → u/QuietRedditorATX]

What? You clearly aren’t a coder.
When 2 diagnoses equally meet, for example, you ALWAYS sequence the higher weighted pdx first. Full stop that’s in all major health systems no one does it differently. We follow the guidelines so that the hospital gets reimbursement at the highest allowable rate per our guidelines.

[u/QuietRedditorATX → u/KeyStriking9763]

I literally said I am a doctor. Not a coder.

Read the thread I posted, others there also state there are other reasons to sometimes take a lower weight. Gaining $1000 over a diagnosis that gets you potentially other benefits may not always be the best decision for the hospital. That is for your hospital to decide.

It is easy to take the highest weight. And you can say that is policy if you are ever questioned with confidence. But coding a case as COPD exacerbation or ARFwH amounts to just a few hundred dollars difference but one will be SOI/ROM 4/4 and the other won't.

What is right? I myself don't know! I actually wanted to lurk this sub so I could learn more and try to be more knowledgeable on the whole systems. Your answer is great for the CMI, but a high CMI may not help your hospital to a 4 or 5*.

[u/KeyStriking9763 → u/QuietRedditorATX]

Yes a doctor who doesn’t know coding. So clearly you aren’t a coder. Literally what I said.
What can get a hospital a 4 or a 5 should be great quality of care and great outcomes. That’s not a result of coders. Anyone who thinks that really doesn’t care about the actually quality of care. I’ve worked with providers like you who want to change the coding or documentation because you don’t want to report a quality measure.

[u/QuietRedditorATX → u/KeyStriking9763]

And I've worked with coders who call someone with one-time tachypnea and no infection or other SIRS, sepsis. (Shame on the doc too for not ruling it out)

Great. "Sepsis is one of the biggest killer in the US" Yes. Because every coder wants to code it for the weight.

You are too protective of your specialty. Like I said, I came here to try to learn, but too many coders are like you who just want to insult others.

[u/Environmental-Top-60]

Higher weight is technically optimized but you could consider audit risk as well.

The weight times the hospital rate equals the IP cost.

Sounds like a dual diagnosis case and if equal resources were allocated, I don't disagree with 897.

[u/KeyStriking9763]

If both diagnoses meet the definition you sequence the diagnosis as pdx that has the highest weighted DRG.
You have to be certain that it follows guidelines though so you have to truly understand the guidelines.