Book Excerpt: APR-DRG and the pediatric CDI professional

Having been jointly developed by 3M™ and the National Association of Children’s Hospitals and Related Institutions (NACHRI), the APR-DRG system’s intent was to help describe pediatric patients’ congenital disease processes and depth of resources required to care for complicated pediatric patients. It has since been taken over by other federal and state agencies to provide risk adjustment and quality scoring for the adult population, as well.

Let’s use a cerebral palsy patient as an example of how the APR-DRG coding system works in the pediatric population. Physicians typically diagnose cerebral palsy at birth. It indicates a certain type of brain damage that specifically affects muscle tone, gross and fine motor movement, balance, gait, and posture. The brain damage is permanent but does not progress. Cerebral palsy can be classified by severity:

• Mild: Moves without assistance and can perform activities of daily living (ADL) independently
• Moderate: Braces, medications, and adaptive aids are required for performance of ADLs
• Severe: The patient requires a wheelchair and will not be able to complete most ADLs without maximum assistance

Unfortunately, the APR-DRG system doesn’t allow for coding of “severe cerebral palsy.” The accurate level of the severity of pediatric patient’s cerebral palsy is obtained in the APR-DRG system by the provider documenting a detailed description of the type of cerebral palsy along with secondary conditions/diagnoses that are being monitored, evaluated, assessed, or treated (MEAT).

The specific type of cerebral palsy affecting the pediatric patient is defined by the type of muscle impairment and the extent of the impairment (spastic monoplegic cerebral palsy, dystonic hemiplegic cerebral palsy, ataxic diplegia cerebral palsy, etc.). There is not a great level of distinction made between the types of cerebral palsy by the APR-DRG system.

Most the of cerebral palsy types code to the APR-DRG of 058, Other Disorders of the Nervous System, but atheoid cerebral palsy codes to APR-DRG 042, Degenerative Nervous System Diseases Excluding MS, and has a higher RW and LOS than APR-DRG 058, so the physician needs to document the most accurate and consistent description of the type of cerebral palsy in the pediatric patient’s health record for accurate code assignment.

Editor’s note: This is an excerpt from the recently released book Pediatric CDI: Building Blocks for Success.