Can Medicare Prospective Payment Survive the ICD-9-CM Disease Classification System?

Abstract

The Medicare prospective payment system represents a fundamental change in hospital payment. The diagnosis-related group (DRG) patient classification scheme serves as the modifier of payment for this system. The DRG definitions are, in turn, based on the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM). Deficiencies in the ICD-9-CM coding system directly affect the equity of the Medicare payment system. A review of the ICD-9-CM system identifies three principal problems: the inability of the system to reflect clinically important patient attributes adequately; the use of outcome, rather than approach, to code surgical procedures; and the blurring of clinical specificity by the adoption of certain coding rules. If these deficits in coding specificity are not corrected, it is unlikely that DRGs will adequately distinguish clinically unique types of patients. This inability to differentiate among patients threatens to undermine the equity of Medicare payments. Physicians must become more aware of disease coding and more involved in its development and implementation.

Admission and mid-stay MedisGroups scores as predictors of death within 30 days of hospital admission.

“…The information contained in Medicare's administrative files is confined to basic demographic, diagnostic, and procedural data not considered adequate to the task of severity adjustment by some critics. [3][4][5][6][7] The purpose of this research was to examine the performance of MedisGroups®, a severity measurement system based on data drawn from the medical record, as a predictor of mortality.…”

Accuracy of ICD-9-CM Codes in Identifying Reportable Communicable Diseases

“…Lloyd and Rissing (19) found that the source of error on Veterans Administration discharge abstracts was physicians 62% of the time, clerical coders 35%, and keypunchers 3%. The ICD-9-CM system, and proposed 10th version, have been criticized both from those oriented to hospital practice-mainly due to problems arising from its use in determining diagnosis-related groups-and primary care specialists (20,21).…”

A Chance of Cure for Every Patient with Chronic Myeloid Leukemia?

“…Furthermore, exacerbation of right ventricular distention by volume loading may in part explain why this therapeutic intervention does not improve cardiac output and systemic arterial pressure in patients with right ventricular infarction. 15 Inotropic therapy added to volume loading has been successful in improving right ventricular stroke output and systemic arterial pressure in patients with hemodynamically important right ventricular infarction. 15 However, this therapy may increase the oxygen demand in the left ventricle, thereby inducing ischemia and arrhythmias.…”