Understanding DRG 003 – Tracheostomy with Ventilator and Serious Condition

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DRG 003 – Tracheostomy with Long Ventilation and Serious Illness

In hospital, sometimes we get very sick patients who stay long time and need big treatments. One of these serious cases go to DRG 003. This DRG is for patients who get tracheostomy or ECMO and stay on ventilator for more than 96 hours, and also have major diagnosis that is not from face, mouth, or neck area. Also, patient must have at least one MCC (major complication or condition).

This DRG is not based on diagnosis like other DRGs. It is based on procedures, and it comes in Pre-MDC category. These are highest-level DRGs for very complex patients.


Example Case: Mistake in Procedure Coding Changed the DRG

In one real case, a patient came to hospital with stroke and later needed tracheostomy to help with breathing. During this surgery, doctor did division of isthmus to reach the trachea. This is normal step when doing tracheostomy.

But coder coded it as separate surgery, thinking it is a different procedure. Because of this, wrong DRG was assigned. Later, audit team reviewed and saw this division is part of tracheostomy, not separate. So they deleted that code, and DRG was corrected to the proper one, most likely DRG 003, because patient was on ventilator more than 96 hours and had serious condition.

This shows how small mistake can change DRG and maybe affect payment also.W


Which Patients Come in DRG 003?

This DRG is used when patient is very sick and needs breathing help for long time. Some examples:

  • Severe ARDS or lung failure cases
  • Patient with stroke or brain injury who cannot breathe well
  • Patients with sepsis or multi-organ failure
  • People with neuromuscular disease like ALS
  • Complicated COVID-19 or bad pneumonia
  • Burn cases needing airway protection

But to go in DRG 003, the case must meet these:

  1. Tracheostomy or ECMO done
  2. Mechanical ventilation more than 96 hours
  3. Principal diagnosis not related to face, mouth, or neck
  4. At least one MCC like sepsis, shock, or acute renal failure.

DRG 003 is close to the start of DRG list. Here is small comparison:

  • DRG 001 – Heart transplant with MCC
  • DRG 002 – Heart transplant without MCC
  • DRG 004 – Tracheostomy with major diagnosis, but maybe no long ventilation

DRG 003 is more specific – it needs ventilation more than 96 hours and principal diagnosis not face/mouth/neck.


Important Things to Check in Documentation

To assign DRG 003 correctly, coders should check:

  • Is there note about ventilation time – more than 96 hours?
  • Is MCC clearly written and coded?
  • Did patient really get tracheostomy or ECMO?
  • Did coder avoid adding extra procedure codes for small surgery steps?

In the earlier case, division of isthmus was wrongly added as separate code. Coders must know this is part of tracheostomy and should not be coded alone.

Also, if something is not clear in chart, coder should query doctor to confirm.

Reimbursement Info

DRG 003 has high payment from insurance or Medicare, usually between $60,000 to $100,000, depending on hospital and area. It reflects that patient needed long ICU stay and many treatments.

If DRG is not coded properly, hospital may lose money or face compliance problems. So accuracy is important.

DRG 003 is for patients who are very critical and need long ventilator, tracheostomy, and have serious condition. Coders must be very careful with procedures and documentation. Even one wrong code, like extra surgery step, can change DRG.

Understanding this DRG well helps to keep hospital coding correct, and it shows how serious and expensive the care was for patient.

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