DOCUMENTATION AND DRG’S
for the Hospital Inpatient Coder
J. K. Sturgeon, C.C.S.
Developed by Patient Financial Services
University of Texas Medical Branch at Galveston
Galveston, Tx. 1
DOCUMENTATION AND DRG’s
A general guide
How DRG’s work
How they affect the
How the provider affects
What should be
documented in order to
assure the most
appropriate DRG for each
UT MB Updated October
Galveston, Tx. 2001 2
Basic information on DRG’s
What they are and how they work
General documentation needs to
assure the appropriate DRG for
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DRG’s: How do they work?
How do we use them?
DRG’s GROUP PATIENTS WITH SIMILAR RESOURCE
CONSUMPTION AND LENGTH-OF-STAY PATTERNS.
THERE ARE 523 DRGs AVAILABLE.
EACH DRG HAS A “RELATIVE WEIGHT.” The higher the relative
weight, the greater the average resource consumption. This is used to
calculate reimbursement to the hospital for DRG-based payors like
Medicare (and in some states, Medicaid, Blue Cross, and others).
DRG’s ESTABLISH OUR CASE MIX INDEX. This is an average of
the relative weights of all of the hospital admissions being evaluated. This
in turn is an indicator of the severity / complexity of patient population.
DRG’s ARE USED FOR: determining hospital reimbursement,
budgeting, managed care contracts, economic profiling, physician
profiling, case management, residency program justification, and more.
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DRG: DIAGNOSIS-RELATED GROUP
What affects the DRG assigned for the patient?
AGE OF PATIENT
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Principal Diagnosis: The condition, established after
study, to be chiefly responsible for causing the admission of
the patient to the hospital.
Complication: Any condition that arises during the
Co-morbidity: Any pre-existing or chronic condition that
the patient already has upon admission to the hospital.
Principal Procedure: A procedure performed for
definitive treatment rather than for exploratory or diagnostic
purposes, or that was necessary to treat a complication. The
principal procedure is usually related to the principal
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What documentation is needed?
THIS SHOULD BE AS SPECIFIC AS POSSIBLE!
ADMITTED FOR MORE THAN ONE REASON? (CHF and
COPD; metastatic workup and chemotherapy)
ACUTE vs. CHRONIC? (respiratory failure in an asthma patient;
fluid overload in an ESRD patient; ARF in a patient with chronic
UNDERLYING CAUSE? (chest pain due to C.A.D., or
osteomyelitis due to Diabetic foot ulcer)
UNCONFIRMED DIAGNOSIS AT DISCHARGE? A condition
that is “probable”, “possible”, or treated as if it exists should be
documented as such. Examples: “fever, probably due to viral
respiratory infection” or “clinical sepsis, treated, not ruled out.”
Physicians‟ Billing staff needs the known diagnosis or symptoms;
inpatient coders need the probable cause of those problems.
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What documentation is needed?
Documentation of all diagnoses that, on this admission, require: clinical evaluation, therapeutic
treatment, diagnostic procedures, an extended hospital stay, or increased nursing care or
monitoring (and in newborns, that have indications for future healthcare needs.)
Chronic conditions: all current problems receiving care should be listed. (DM, CHF, AFib,
COPD, HTN, ESRD, and so forth)
Pt. receiving Meds? There should be a diagnosis associated with each medication. (e.g. “Lasix,
xx/qd for control of CHF)
Are lab tests ordered? When there is a known or suspected diagnosis associated with the
problem, it should be documented in the patient record. The lab order slip requires the known
symptom or problem, but the inpatient record can also use the suspected cause for more
specific coding. (“probable UTI” or “R/O sepsis)
Are X-rays ordered? Same rule as labs: the order slip must have the known problem that
justifies the test, but the inpatient record can also use the suspected cause. (e.g. “suspected
pneumonia”, “rule out aspiration pneumonia”, “probable CHF”, “symptoms of atelectasis”,
Positive lab results? What do they mean? (e.g. low H & H.... is this anemia or dehydration or
neither? Elevated creatinine...... renal insufficiency? urinary obstruction? Positive urine
rbc‟s.... UTI? Kidney stone? Hematuria?)
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COMPLICATIONS AND COMORBIDITIES
Documentation of the following diagnoses can increase factors that determine the severity of
illness & risk of mortality, and justify resources utilized for the hospital inpatient. and justify
resources utilized for the hospital inpatient.
Diabetes: if documented as Pneumonia
uncontrolled or insulin dependent Hyponatremia, Hypovolemia
COPD, emphysema Volume Overload
Decubitus ulcer Post-op complications: infection,
Angina graft failure, dehiscence,
Anemia due to blood loss atelectasis, wound seroma or
Respiratory Failure hematoma, ileus, urine retention
Urinary Tract Infection Thrombocytopenia, coagulopathy
Congestive Heart Failure Hematuria
Chronic or Acute Renal Failure Atrial fib, flutter, heart blocks
Hyperkalemia, Hypernatremia disorders
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SURGERIES AND PROCEDURES:
DOCUMENTATION MUST BE SPECIFIC, COMPLETE, AND
Documentation should include who, what, when and how, and how
What was the tissue; how was it obtained? (e.g.: lung bx. or only
bronchus bx.) Was there a scope, open, or closed procedure? Did they
incise, excise, cauterize, or laser ablate? Skin excision only, or also
muscle / fascia / soft tissue? How large is the wound repaired or the
“I & D” - is this “incision and drainage”, or “incision and
debridement”? Or is it really “excisional debridement”? Or all of the
Description should be as specific as possible:this determines intensity
of service as well as reimbursement for both physician‟s and hospital
billing, inpatient and DSU.
Name of attending M.D. and resident need to be legible to assure that
they receive credit for performing the procedure.
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determined by secondary diagnoses
indicate how sick the patients really are
justify greater resource consumption
improve M.D.‟s “physician profile”
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Each APR-DRG is split into 2 groups, with 4
grades of severity in each group
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Specific documentation needs
Common diseases and disease processes; specific
documentation needs for each.
Symptoms that may be assigned to more appropriate
DRG‟s with more specific documentation.
Procedures that may have technical documentation
requirements to assure the appropriate DRG and
justify resource consumption.
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COPD: asthma, emphysema, bronchitis
Acute Exacerbation... what is it? Respiratory failure,
status asthmaticus, bleb, pneumonia, acute bronchitis?
If pneumonia... is it bacterial? Which bug? Viral? Is it
aspiration pneumonia, interstitial pneumonia?
Are there other contributing pathologies? (e.g. pleural
effusion, congestive heart failure, volume overload,
congenital problems, or chronic diseases like fibrosis or
Acute, chronic, or both should be specified when they
apply to the patient.
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The suspected cause should ALWAYS be documented. (e.g. “pneumonia due to
HIV infection”, “interstitial pneumonia”, “probable Pseudomonas pneumonia”,
“pneumonia likely due to Staph.”) Sputum cultures may well be negative if the
patient was on outpatient antibiotics, or if the specimen or its processing were
not optimal. Coders are prohibited from assuming that the bacteria in the
sputum caused the pneumonia: the doctor must document the cause.
Different organisms and different etiologies can result in different DRG‟s,
severity of illness, risk of mortality, and hospital resources consumed.
Unlike outpatient billing, inpatient accounts can be reimbursed for “suspected,
probable, possible” diagnoses based on resources used to treat the suspected
If a problem is treated presumptively, it is coded unless it has been ruled out,
and is reimbursed accordingly. (e.g. “pneumonia suspected due to gram
negative organism” in a patient who has failed outpatient abx., or “suspected
aspiration pneumonia” in a nursing home patient with dysphagia & aspiration
problems from an old CVA)
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What caused the respiratory failure? This can determine the
final DRG. (e.g. “respiratory failure due to acute exacerbation
of COPD”, “respiratory failure due to CHF”, or “respiratory
failure due to CHF and pneumonia”)
The patient need not be on a ventilator; the diagnosis can be
based on medical criteria including respiratory rate and arterial
“Arrest” is not synonymous with “Failure” for coding and DRG
assignment. Is the “cardiorespiratory arrest” actually
“respiratory failure” and “cardiac arrest”?
There is no way to code, or to assign a DRG, for “Multi-Organ
System Failure”... each organ system must be listed separately.
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U.T.I. and “UROSEPSIS”
The diagnosis of “urosepsis” is coded and reimbursed the same as is
a “U.T.I.”... it is considered to be an unspecified infection of
ONLY the urinary system.
“Septicemia and (or „due to‟) a U.T.I.” should be documented as
separate diagnoses. This greatly affects severity of illness, risk of
mortality, and can affect the DRG and hospital reimbursement as
“Clinical Sepsis” in the patient should always be documented, even
in the absence of positive blood cultures. The symptoms from which
this diagnosis is made should also be clearly documented.
Related complications that may arise should be noted as well: urine
retention, ARF, pyelonephritis, and the like.
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Is the hypertension benign or malignant ?
“Uncontrolled” does not designate malignant
Which of the patient‟s symptoms / systems does the
hypertension affect? (Hypertensive Renal Disease,
Hypertensive Heart Disease, Hypertensive
What caused the hypertension? (e.g. renal artery
stenosis, PCKD, chronic pyelonephritis,
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What caused the renal failure? (e.g. diabetes, hypertension, SLE,
PCKD, radio-opaque dye, other?)
Is this Acute, Chronic, or Acute and Chronic failure?
What does “near-ESRD” mean? It will be coded as “renal
insufficiency” unless it is further specified.
If a transplant patient is admitted, is it due to a complication of the
What is that complication...ATN, CMV, ARF, rejection, infection,
Related diagnoses should be documented if they are treated,
evaluated or monitored, or if they extend the hospital stay. Included
should be volume overload, electrolyte imbalances, urine retention,
and the like.
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Is this AODM (type II, usually adult-onset) or IDDM (type I, usually
Is the diabetes “uncontrolled” or does it have “poor control” on this
“Insulin-controlled” and “currently insulin-requiring” do not mean
“insulin-dependent” for coding or DRG assignment.
Adult-onset diabetes can still be “insulin-dependent” if it is now a
permanent requirement for treatment.
Is this patient‟s cellulitis/foot ulcer/osteo/ESRD/etc. due to the diabetes?
Even more critical: is it due to Diabetic neuropathy? Diabetic PVD?
Diabetic nephropathy or cardiomyopathy?
The above conditions should ALWAYS be documented when they
apply to a particular patient.
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Hypertensive heart disease
Secondary diagnoses that have Post-myocardial infarction syndrome
an origin or effect that is Septal thrombus... is this Acute or Chronic?
Symptomatic? Old MI?
cardiovascular can have Cardiomyopathies…what type? Cause?
significant impact on severity, Cardiogenic shock, shock not due to trauma
mortality risk, and V-tach, PSVT, A-fib, A-flutter, V-fib or V-flutter
reimbursement. Congestive Heart Failure, Acute Cor Pulmonale
Conditions on the list to the Angina - stable, unstable, prinzmetal?
Asystole, cardiac arrest, heart blocks
right should be documented if
( Mobitz, A.V., trifascicular...be specific!)
they are treated, or evaluated, Acute Renal Failure
or monitored, or if they Pulmonary embolus or infarction
increase hospital stay or Myocarditis, Endocarditis
nursing care / monitoring. Valve disorders - prolapse, insufficiency,
Rheumatic heart disease
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CVA or TIA
Is this due to (or probably due to) an infarct? thrombus?
Is it (probably?) due to cerebral atherosclerosis, stenosis or
Is a specific site of the obstruction known – or suspected? (e.g.
cerebral artery; pre-cerebral or carotid artery)
If the “TIA” symptoms last more than 72 hours, is this really a
Residuals still present at discharge should be clearly
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ARTERIAL or VENOUS OCCLUSION
What is the (suspected) cause of the
Atherosclerosis or plaque?
Stricture or stenosis?
External compression (e.g. tumor or
Diabetic vascular disease?
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Is the reason for admission caused by the HIV
infection? (e.g. “fever probably due to HIV” or
“recurrent community-acquired pneumonia due to
All co-existing problems being treated, evaluated,
monitored, or extending the hospital stay should be
listed at least one time. (e.g. candidiasis, PCP,
dehydration, cryptococcosis, diabetes, etc.)
The current T-cell or CD4 count should be documented
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What is the ACUTE reason for the patient‟s admission? Pain control?
Mets. workup? Surgery to primary site? Dehydration? Palliative care
ONLY? Neutropenic fever.... or neutropenia with suspected sepsis or
infection? Chemotherapy ONLY? Intractable nausea due to chemo? Post-
Once on each admission, the primary site and all current metastatic sites
being addressed on this admission should be listed. It should be specific...
“mets. to bladder, colon and liver (or applicable sites)”, NOT “abdominal
Is the cause of the symptoms at admission known or suspected? (e.g. “urine
retention due to bladder cancer at UVJ” or “urine retention probably due to
external compression from peritoneal mets.”)
All secondary conditions being treated or monitored should be documented.
Examples: CHF, COPD, AODM, anemia (blood loss?), electrolyte
imbalances, infections, coagulopathies, and so forth.
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G. I. BLEED
Can the bleeding be more specifically described as melena, hematochezia,
If a source of the bleed is known or suspected, inclusion in the discharge
progress note would be most helpful.
Endoscopy notes should include the cause of the bleed as well as the
physical findings. Does “gastric ulcer, no active bleed” mean that the ulcer
is NOT the cause of the bleed? Or that despite no current bleeding, we
presume the ulcer to be the cause?
If workup reveals gastritis, an erythematous polyp, internal hemorrhoids
and a healing gastric ulcer: A) is a specific one of these suspected to be the
cause of the bleed? B) might any of them be the cause? C) are none of them
severe enough to be causing the bleed, and the patient needs further
Failure to have the cause, or suspected cause, documented can affect DRG
assignment, reimbursement to the hospital, and severity of illness indicators
for the patient.
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What is the ACUTE reason for admission... pre-eclampsia? Gestational diabetes?
Preterm labor? Dehydration?
Is the reason for admission unrelated to the pregnancy? (e.g.: “patient with broken
ankle for ORIF, 18 wk. incidental pregnancy” or “patient with second degree
burns to ankle, 22 wk. pregnancy unaffected by injury.”)
It should be specified when diagnoses have their origin in the postpartum period.
(e.g. “postpartum uterine atony”or “postpartum” fever) These are coded, and
reimbursed, differently than if they are not specified as ante- or post-partum.
If this is a preterm or postmature delivery, documentation should state this
specifically as such rather than just documenting estimated weeks.
Did the patient have insufficient prenatal care? Is she a high-risk patient?
All diagnoses that are monitored / evaluated / treated should be documented. (e.g.
endometritis, venereal diseases, pre-eclampsia, all anemias, UTI, other infections,
placenta problems - retained, abruptio, etc., diabetes and hypertension -gestational
or chronic?). Is there a diagnosis associated with “+GBBS” or
“+ WBC’s in urine”?
Post-operative problems should be documented as well. (e.g. wound dehiscence,
hematoma, seroma, or infection; spinal headache, ileus or atelectasis)
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Is the infant Preterm? Is this Extreme Prematurity?
If baby has respiratory problems, specify whether they are due to: HMD, RDS, TTN, apnea
(of prematurity?), meconium aspiration syndrome, pneumonia, pneumothorax, anemia,
hypoplastic lung, and so forth. Document all that apply.
Is the baby hypoglycemic? Hypovolemic? Hypotensive? (“hypoperfusion” cannot be coded – a
specific diagnosis should be listed if possible) Hypocalcemic? Other transient electrolyte
Why are we “ruling-out sepsis”? Maternal chorio? Symptomatic baby? Did we rule it out? If
not, “clinical sepsis” can be documented if sepsis is presumed even in the absence of positive
blood cultures. If it isn’t sepsis, the suspected cause of the baby’s symptoms should be
Does any specific diagnosis extend the stay? The reason should be noted.
Are maternal drugs or meds. affecting the infant? How?
Are there any congenital infections, or suspected infections? Diagnosis should be specific....
pneumonia, conjunctivitis, viral syndrome, etc.
Heart murmur... insignificant or functional? Probable PDA? Or does it need follow-up
because it is still undiagnosed at discharge?
Diagnoses that need follow up after discharge, should be listed individually on the nursery
discharge summary at line 6 “Needs follow-up for:”
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Is the cause of the fever known, or suspected, at discharge? If so, it is best to
have this documented in the discharge progress note and discharge summary.
For example: “Fever, probably due to subacute bacterial infection.” or “Fever,
suspect due to viral syndrome”... or to gastroenteritis, or influenza, or to the
diagnosis that is the most likely cause of fever in the patient.
Was the suspected cause ruled-in, ruled-out, or still suspected at discharge? For
example: “Patient admitted to rule out sepsis. Cultures negative at 36 hours;
sepsis ruled out. Fever probably due to chronic sinusitis and viral URI.”
“Suspected, not ruled out” is coded as if it exists in an inpatient setting, because
it consumes resources as if it does exist.
In the event that a particular cause is not “known or suspected” at discharge, it
is acceptable to use a differential list in addition to the diagnosis of fever.
In a patient admitted for “neutropenic fever”, are we actually admitting the
patient to treat a “suspected bacterial infection” ?
Accurate information results in accurate severity-of-illness indicators, and can
also increase hospital reimbursement.
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At discharge, the record should clearly state what is believed, or suspected, to
have caused the patient‟s chest pain.
Was it (probably?) due to angina? Unstable angina?
If so, what caused the angina? An M.I.? If not, is it due to underlying C.A.D.?
If the patient has minimal or no C.A.D., due we instead suspect the anginal
pain to be caused by anemia? Vasospasm? Hypertension?
If the chest pain is probably not due to angina, is it still cardiac in origin? A
small non-q wave M.I. as evidenced by Troponin T results? Alcoholic
cardiomyopathy? Chronic ischemic heart disease? Some type of arrhythmia?
If the chest pain is of non-cardiac origin, what is the probable cause?
G.E.R.D.? Hiatal hernia? Dyspepsia? Peptic ulcer disease? Costochondritis?
Musculoskeletal strain? Psychogenic chest pain or psychogenic angina?
A major factor in determining the final hospital DRG is the PROBABLE
CAUSE of the chest pain for which the patient was admitted.
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ABNORMAL LAB VALUES
In order for the DRG assignment to reflect the appropriate severity of illness
of the patient, there must be an associated DIAGNOSIS, documented by a
physician, in this admission of the medical record.
“+ GBBS”.... Is this an infection? Of what site? Is this a colonization? Is it
suspected to be a contaminant only? Is the patient a suspected carrier of
“++ wbc’s, ++ rbc’s & bacteria in urine”.... Is this a U.T.I.? An infection due
to indwelling Foley catheter? A kidney stone? Other? Neither?
“++ Hep B/C”... Is this a current infection? If so, is it “Active” or “in
Remission”? Are we treating, monitoring, or evaluating it in some manner on
this admission? Or is it only a “history of” or “exposure to” hepatitis?
“PIH with proteinuria”.... This should be documented as “pre -eclampsia” if
it is actually the condition being treated.
A “down-arrow” or an “up-arrow” is not a diagnosis with Na or K values.... it
merely designates an abnormal or a changed lab value. If the patient has
clinical Hyponatremia or Hyperkalemia, it should be documented as such.
The same applies to hematocrits as well as to other laboratory results in
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Is this radiosurgery?
Is it a “closed” procedure? (burr hole access only)
Is it electrocautery? Excision? Destruction by
If this is an excision, is a total excision of the
lesion in question, or is it a partial (debulking)
Is this a biopsy only, rather than an excision of the
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What is being debrided... skin / subcutaneous tissue?
Fascia? Muscle? Bone? All of the above?
Is this a debridement of an open fracture?
Is this SHARP or EXCISIONAL debridement?
To affect DRG assignment as a procedure, the
debridement of skin and subcutaneous tissue must be
documented as excisional or sharp debridement in a
It need not be done in the O.R., and it can be done by
staff other than a physician.
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Why we converted an outpatient procedure or surgery (DSU) to
an inpatient admission should always be documented.
Was the patient admitted as an inpatient for post-op urine
retention? Fever? Atelectasis? Nausea/vomiting due to meds?
Arrhythmia? Other problem unrelated to surgery? (e.g. diabetes
or hypertension control)
Was the inpatient admission for surgical aftercare only? (e.g.
pain control, uncomplicated anesthesia recovery)
Would it have been more appropriate to assign to 23-hour
observation, and then re-evaluate the need for admission? If we
then change to admission status the diagnosis that caused the
inpatient stay needs to be documented clearly
All of the above affect final DRG assignment.
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LYMPH NODE PROCEDURES
The procedure note should specify clearly the particulars.
Is this a simple node biopsy?
Is it a simple node excision?
Is it a “radical” (neck or other) dissection?
Is it a regional excision? (with node, skin, subcutaneous
tissue and fat)
If this is excisional, are we also taking muscle? Fascia?
Procedure variations can affect both severity and
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