Diagnosis Related Groups Assigned to Major Diagnostic Categories

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This dataset contains all 25 MDCs (Major Diagnostic Categories), along with the DRGs assigned to each MDC. The data is organized by MDC with a list of the surgical classes associated with that MDC listed in hierarchical order as well as the MS-DRGs that are included in each surgical class.

Complexity

A Diagnosis-Related Group (DRG) is a statistical system of classifying any inpatient stay into groups for the purposes of payment. The DRG classification system divides possible diagnoses into 25 major body systems and subdivides them into one of 747 groups for the purpose of Medicare reimbursement. DRG grouper system has been used by Medicare since 1983 to reimburse hospitals for inpatient admissions. Factors used to determine the DRG payment amount include the diagnosis involved as well as the hospital resources necessary to treat the condition. Also used by a few states for all payors and by many private health plans (usually non-HMO) for contracting purpose. Hospitals are paid a fixed rate for inpatient services corresponding to the DRG group assigned to a given patient.

Beginning in 2007, CMS overhauled the DRG system with the development of “severity-adjusted DRGs.” Specifically, beginning in October 2007, CMS began to replace DRGs with “Medicare-severity DRGs” or “MS-DRGs” through a three-year phase-in period that blended payment under the old DRG system and the MS-DRG system. While there are similarities between the two systems in the existence or absence of complications or co-morbidities, the MS-DRG system adds a third category – “Major complications and/or co-morbidities.” Cases are classified into MS-DRGs for payment based on the principal diagnosis, up to eight additional diagnoses, and up to six procedures performed during the stay. In a small number of MS-DRGs, classification is also based on the age, sex, and discharge status of the patient. The diagnosis and discharge information is reported by the hospital using codes from the IC-9-CM (the International Classification of Diseases, 9th Edition, Clinical Modification).

The Major Diagnostic Categories (MDC) are formed by dividing all possible principal diagnoses (from ICD-9-CM) into 25 mutually exclusive diagnosis areas. MDC codes, like diagnosis-related group (DRG) codes, are primarily claims and administrative data element unique to the United States medical care reimbursement system. DRG codes also are mapped, or grouped, into MDC codes. The diagnoses in each MDC correspond to a single organ system or etiology and, in general, are associated with a particular medical specialty. MDC 1 to MDC 23 is grouped according to principal diagnoses. Patients are assigned to MDC 24 (Multiple Significant Trauma) with at least two significant trauma diagnosis codes (either as principal or secondary) from different body site categories. Patients assigned to MDC 25 (HIV Infections) must have a principal diagnosis of an HIV Infection or a principal diagnosis of a significant HIV related condition and a secondary diagnosis of an HIV Infection.

MDC 0, unlike the others, can be reached from a number of diagnosis/procedure situations, all related to transplants. This is due to the expense involved in the transplants so designated and because these transplants can be needed for a number of reasons which do not all come from one diagnosis domain. DRGs which reach MDC 0 is assigned to the MDC for the principal diagnosis instead of to the MDC associated with the designated DRG.

Since patients can have multiple procedures related to their principal diagnosis during a particular hospital stay, and a patient can be assigned to only one surgical class, the surgical classes in each MDC are defined in a hierarchical order. Patients with multiple procedures are assigned to the highest surgical class in the hierarchy to which one of the procedures is assigned. Thus, if a patient receives both a D&C and a hysterectomy, the patient is assigned to the hysterectomy surgical class because a hysterectomy is higher in the hierarchy than a D&C. Because of the surgical hierarchy, ordering of the surgical procedures on the patient abstract or claim has no influence on the assignment of the surgical class and the MS-DRG.

The surgical hierarchy for each MDC reflects the relative resource requirements of various surgical procedures. In some cases a surgical class in the hierarchy is actually an MS-DRG. For example, Arthroscopy is both a surgical class in the hierarchy and
MS-DRG 509 in MDC 8, Diseases and Disorders of the Musculoskeletal System and Connective Tissue. In other cases the surgical class in the hierarchy is further partitioned based on other variables such as complications and comorbidities, or principal diagnosis to form multiple MS-DRGs. As an example, in MDC 5, Diseases and Disorders of the Circulatory System, the surgical class for permanent pacemaker implantation is divided into three MS-DRGs (242-244) based on whether or not the patient had no CCs, a CC or an MCC.

Date Created

2016-10-01

Last Modified

2018-05-12

Version

35.0A

Update Frequency

Annual

Temporal Coverage

N/A

Spatial Coverage

United States

Source

John Snow Labs => Centers for Medicare & Medicaid Services

Source License URL

John Snow Labs Standard License

Source License Requirements

N/A

Source Citation

N/A

Keywords

DRG codes, Diagnosis group, Cms drg, Major Diagnostic Categories, MDC, MDCs, MSDRGs

Other Titles

DRG Codes Assigned to Major Diagnostic Categories, Diagnosis Group Assigned to Major Diagnostic Categories

NameDescriptionTypeConstraints
Major_Diagnostic_Category_CodeMajor Diagnostic Category that divides all possible principal diagnoses (from ICD-9-CM) into 25 mutually exclusive diagnosis areasstring-
Description_of_Major_Diagnostic_Category_CodeDescription of the MDC Codestring-
Diagnosis_Related_Group_CodeDiagnosis Related Group code ( from 1 to 999)string-
Description_of_Diagnosis_Related_Group_CodeDescription of the DRG Codestring-
Major_Diagnostic_Category_CodeDescription_of_Major_Diagnostic_Category_CodeDiagnosis_Related_Group_CodeDescription_of_Diagnosis_Related_Group_Code
MDC 00Pre-MDC7Lung Transplant
MDC 00Pre-MDC10Pancreas Transplant
MDC 00Pre-MDC14Allogeneic Bone Marrow Transplant
MDC 00Pre-MDC005-006Liver or Intestinal Transplant
MDC 00Pre-MDC8Simultaneous Pancreas/Kidney Transplant
MDC 00Pre-MDC016-017Autologous Bone Marrow Transplant
MDC 02Diseases & Disorders of the Eye113-114Orbital Procedures
MDC 01Diseases & Disorders of the Nervous System023-027Craniotomy
MDC 02Diseases & Disorders of the Eye116-117Intraocular Procedures
MDC 00Pre-MDC011-013Tracheostomy for Face, Mouth and Neck Diagnoses