Requesting That Delirium Achieve Parity With Acute Encephalopathy in the MS-DRG System

Area of Science:

• Healthcare policy
• Medical coding
• Neurology

Background:

• Medicare Severity Diagnosis Related Groups (MS-DRG) classification favors acute encephalopathy codes over delirium codes for reimbursement and quality metrics.
• This disparity exists despite significant overlap between diagnostic codes, leading to under-recognition of delirium's complexity.
• Toxic and metabolic encephalopathy codes are classified as Major Complications or Comorbidities (MCC), while delirium codes are Complications or Comorbidities (CC).

Purpose of the Study:

• To advocate for reclassifying causally specified delirium as a Major Complication or Comorbidity (MCC) within the MS-DRG system.
• To align delirium's classification with its clinical significance and impact on patient outcomes.
• To address the inequity in reimbursement and quality metric evaluation for patients with delirium.

Main Methods:

• A submission was made to the U.S. Centers for Medicare and Medicaid Services (CMS) requesting reclassification of delirium.
• The proposal was supported by evidence demonstrating delirium's alignment with CMS criteria for severity level re-evaluation.
• The potential impact of reclassification was analyzed using the 2019 National Inpatient Sample.

Main Results:

• Delirium meets CMS criteria for re-evaluation, including its bidirectional relationship with dementia, population vulnerability, and impact across care levels.
• Analysis of the 2019 National Inpatient Sample suggested that reclassifying delirium as MCC would result in less than 1% upcoding of eligible discharges.
• The study highlights that parity for delirium coding is essential for recognizing its clinical and economic burden.

Conclusions:

• Reclassifying delirium as an MCC is crucial for accurate reimbursement and quality assessment.
• Achieving parity for delirium coding will enhance awareness of its substantial clinical and economic costs.
• This reclassification is expected to encourage delirium prevention and screening, ultimately mitigating adverse outcomes for patients and healthcare systems.