New Mexico Medical Review Association (NMMRA)

1. New Mexico Medical Review Association (NMMRA) Coding forPayment Accuracy

2. DRGs 079, 080, 089 and 090

3. Comparative DRGs DRG 079 - Respiratory infection and inflammation, age 18 or older, with CC DRG 080 - Respiratory infection and inflammation, age 18 or older, without CC DRG 089 - Simple pneumonia and pleurisy, age 18 or older, with CC DRG 090 - Simple pneumonia and pleurisy, age 18 or older, without CC

4. DRG 079 Relative Weight (RW) 1.6501 Length of Stay (LOS) 8.5 Projected payment $6,765* DRG 080 Relative Weight (RW) 0.9373 Length of Stay (LOS) 5.8 Projected payment $3,843* Comparative DRGs • Projected payment based on average Medicare base rate for 1998

5. DRG 089 Relative Weight (RW) 1.0647 Length of Stay (LOS) 6.0 Projected payment $4,365* DRG 090 Relative Weight (RW) 0.6590 Length of Stay (LOS) 4.2 Projected payment $2,702* Comparative DRGs • Projected payment based on average Medicare base rate for 1998

6. DRGs 079, 080, 089 and 090Issues • Simple pneumonia vs. complex pneumonia • Documentation

7. Simple vs. Complex Pneumonia DRGs 079, 080, 089 and 090 1) Adenovirus 2) Respiratory syncytial virus (RSV) 3) Parainfluenza virus 4) Other and unspecified viral 5) Pneumococcal (streptococcus pneumoniae) (lobar) • Organisms classified as simple pneumonia

8. Simple vs. Complex Pneumonia DRGs 079, 080, 089 and 090 6) Hemophilus influenzae 7) Streptococcus (A, B, other) 8) Unspecified bacteria 9) Mycoplasma pneumoniae 10) Chlamydia 11) Unspecified organism

9. Simple vs. Complex Pneumonia DRGs 079, 080, 089 and 090 1) Klebsiella 2) Pseudomonas 3) Staphylococcus (aureus, other and unspecified) • Organisms classified as complex pneumonia 4) Anaerobes 5) E. coli 6) Gram-negative bacteria 7) Legionnaires’ 8) Other specified bacteria

10. Simple vs. Complex Pneumonia DRGs 079, 080, 089 and 090 1) Cytomegalic inclusion disease, whooping cough, anthrax, aspergillosis, other systemic mycoses and other infectious diseases classified elsewhere 2) Aspiration pneumonia • Other complex pneumonias

11. - Emergency reports - History and physical (H&P) - Progress notes - Laboratory reports - X-ray reports - Medication sheets - Respiratory therapy notes - Discharge summary - Graphics record DRGs 079, 080, 089 and 090 Documentation • Where to find documentation:

12. - Fever - Chills - Cough - Production of sputum - Quality of sputum - Pleuritic chest pain - Pleural effusion - Tachypnea - Dyspnea DRGs 079, 080, 089 and 090 Documentation • Pneumonia signs and symptoms:

13. Patient was transferred from nursing home Patient has a history of vomiting Patient has a history of difficulty swallowing (dysphagia) Patient has NG tube DRGs 079, 080, 089 and 090 Documentation • Aspiration pneumonia* signs and symptoms: - H&P or emergency department notes indicating: * If aspiration pneumonia is documented or indicated, coder should check for evidence of bacterial pneumonia

14. - Elevated white blood cell count - Chest x-ray — see infiltrates or consolidation - Positive sputum culture DRGs 079, 080, 089 and 090 Documentation • Pneumonia — lab: Note: Physician must make connection between positive sputum culture and pneumonia

15. DRGs 079, 080, 089 and 090 Documentation The physician is responsible for making the diagnosis of pneumonia and determining the type of pneumonia

16. - Antibiotic therapy - Oxygen therapy - Other respiratory therapy - Thoracentesis for pleural effusion DRGs 079, 080, 089 and 090 Documentation • Pneumonia treatment:

17. Contact NMMRA: P.O. Box 3200 Albuquerque, New Mexico 87190-3200 505.998.9898 phone 505.998.9899 fax www.nmmra.org