HIV & Cerebral cryptococcosis
Cerebral cryptococcosis** (B45.1) is identified as a HIV-related illness*, but it is NOT on the list of DRG 974 Major Related conditions with MCC***; as a result the encoder takes you to DRG 977 (HIV with or without other related conditions) instead. Is this Right? It does not make sense, given that meningitis is a MCC (and when PDX, is it's own MCC). Per DRG expert, B45.2 Cutaneous Cryptococcus is more serious!!
The sequencing rules require B20 as the PDX (I think), but DRG 977 is static - the reimbursement is very low, and hardly reflects the significant cost and LOS associated with treating this major brain infection.
When I first started in CDI, my coding manager said 'the list of HIV w/ MCC (ie DRG 974) is NOT complete' - but I did not fully understand at the time what that meant. Now, I'm needing to better understand this: 1) Should B45.1 be on this list 'HIV with Major Related Condition with MCC', 2) If yes, What is the work-around (e.g. add B45.8?), 3) If yes, How do I go about getting this oversight fixed (CDC? Optum? Coding Clinic?), 4) If no, should B45.1 be the principle?
Thank you!
*https://www.aapc.com/blog/34554-hiv-icd-10-dx-coding/
** coding pathways for HIV & 'meningitis d/t cryptococcosis: Crytpococcosis associated with HIV disease, cerebral (B20 PDX, B45.1 secondary).
***DRG Expert 2018. pg 898, MDC 25: Human Immunodeficiency Viris Infections.
Comments
thank you, ab
The difficult part of your question is how is the differentiation of what is considered a major related illness and what is considered other related illness determined? I would assume that is based on the statistics of resource use and this is how DRG weights, CC and MCC influence are determined. there are a number of issues within the MS-DRG system which do not exactly make sense- the determination of how these diagnoses influence DRG weights and assignment is based on the average resource use- these statistics are pulled from the claims submitted nationwide. You have asked can you work around this by coding B45.8 which is listed as a major related illness. B45.8 describes "other forms of crytpococcosis". Unfortunately if you assigned this code to the situation of Cerebral cryptococcosis it would be incorrect.
You ask to whom can you take this concern to- you can ask the CMS to consider this in their annual review. Lets ee what Allen says!