Topic: Multiple Significant Trauma
Scenario: 65 year old male with a PMH of CAD, HTN, and Hyperlipidemia on Metoprolol and Lipitor who presented following a 10 foot fall onto the ground from a ladder while cleaning out the gutters. Per H&P pt. fell on his back striking his head with wife reporting to EMS he was unresponsive for about 10 minutes following the fall. Pt. is currently complaining of abdominal and left leg pain with a headache. EMS notes pt. vomited x1 after their arrival. Pt. is noted to be orientated x3; however is having trouble remembering specific details of the accident. Work-up reveals a fractured left femoral neck on X-Ray. Pt. is admitted with a left fractured femoral neck with plans for an ORIF.
Nursing placed a Foley catheter with return of brown tinged urine. Urinalysis was positive for RBCs, negative for WBC, nitrates and leukoesterase. Abdominal CT demonstrated possible left kidney contusion. Maintenance IVF are continued, Q8 hour H/H & BMP ordered, bed rest and strict I&O. Head CT was ordered which was negative for any acute injury.
Pt. underwent an ORIF of the left femur and had an uneventful post-operative course.
Question: Are there any query opportunities based on the scenario stated above?
Discussion: The Center for Medicare and Medicaid Services (CMS) defines significant trauma as: “Any diagnosis of significant injury to the head, chest, abdomen, kidney, urinary system, pelvis or spine, or upper or lower limb’.
Assignment to MDC 24, Multiple Significant Trauma (MST), is based on more than just the Principal Diagnosis.
Pt. presented with clinical indicators of a concussion and kidney contusion:
- S/P 10 feet fall striking head, positive LOC, vomiting on scene, with confusion/amnesia of incident
- S/P fall onto back, UA with RBC, brown urine and CT demonstrated possible kidney contusion
UASI Recommends:
- Query for Concussion: Concussion with LOS of 30 minutes or less is a CC on it’s own
- Query for Kidney Contusion with specificity of degree: Minor Kidney Contusion is a CC on it’s own, however also accounts for a second significant injury from a different trauma body site category
Documentation without Clarification: Working Principal Dx: Fracture of unspecified part of neck of left femur, initial encounter for closed fracture S72002A
Working Secondary Dx:
- CAD I2510
- HTN I10
- Hyperlipidemia E785
- Fall on and from ladder, initial encounter W11XXXA
- Activity, other involving exterior property and land maintenance, building and construction Y93H9
- Other place in single-family (private) house as the place of occurrence of the external cause Y92018
Working PCS: Reposition left lower femur with internal fixation device, open approach 0QSC04Z
Working DRG: 482 Hip & Femur Procedure Except Major Joint w/o CC/MCC
RW: 1.6453 GMLOS 3.3 SOI/ROM: 1/1
Documentation with Clarification: Working Principal Dx: Fracture of unspecified part of neck of left femur, initial encounter for closed fracture S72002A
Working Secondary Dx:
- CAD I2510
- HTN I10
- Hyperlipidemia E785
- Fall on and from ladder, initial encounter W11XXXA
- Activity, other involving exterior property and land maintenance, building and construction Y93H9
- Other place in single-family (private) house as the place of occurrence of the external cause Y92018
- Concussion with LOC of 30 minutes or less S060X1A
- Minor contusion of left kidney S37012A
Working PCS: Reposition left lower femur with internal fixation 0QSC04Z
Working DRG: 956 Limb Reattachment, Hip & Femur Procedure for Multiple Significant Trauma
RW: 3.9233 GMLOS 6.1 SOI/ROM: 2/1
CDI Educational Tips:
Facilities do not have to be a trauma center to have patients with MST diagnoses, but the PDX must be an injury or trauma diagnosis.
Assignment to MDC 24 is based on a principal diagnosis of trauma, and secondary diagnoses fromsignificant trauma body site categories. There are multiple body site categories for MDC 24, including:
- Significant head trauma
- Significant chest trauma
- Significant abdominal trauma
- Significant trauma of kidney
- Significant trauma of urinary system
- Significant trauma of pelvis or spine
- Significant trauma of upper limb
- Significant trauma of lower limb
Within MDC 24, there are 5 surgical DRGs and 3 Medical DRGs. Once the diagnosis criteria have been met, each surgical DRG has a list of specific ICD-10-PCS codes that qualify for that MS-DRG. OR procedures that do match a procedure code from the Surgical DRGs in MDC 24 are grouped to the Unrelated surgical DRGs 981 – 989. To review the lists of qualifying diagnosis and/or procedures codes for MDC 24, check your grouper software or other available reference books.
To move the Multiple Significant Trauma DRG bundle to a higher severity with CC or MCC, it requires a separate, non-traumatic secondary diagnosis that qualifies as a CC or MCC. While many of the diagnoses included in the Significant Trauma Body Site Categories are considered CCs or MCCs in other MDCs, these will not impact the Multiple Significant Trauma DRG assignment when included as secondary diagnoses.
This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.