MRCs Trump MCCs

The MS-DRG grouper includes a category for “Major Related Conditions” (MRC) associated with AIDS/HIV (see MDC 25 logic). There are 676 ICD-9-CM diagnosis codes that qualify as MRCs, code range 0031-486. The MRCs trump the MCCs, so an AIDS inpatient treated for community acquired pneumonia, (e.g., secondary diagnosis 486) does not group to MS-DRG 974, HIV with Major Related Condition with MCC. Instead, it groups to MS-DRG 976, HIV with Major Related Condition without CC/MCC.Not included as MRCs are conditions like AIDS dementia (042 + 2941x). Read the final paragraph from this article on the HIV Dementia scale, and I think you would agree that this condition should be an MRC. It also makes me wonder why there is no grouper logic for cases with mulitple MRCs. Some of these admissions are for very sick AIDS patients, e.g., those who are non-adherent to HAART or present with multiple opportunistic infections (OI).

So what happens to our Medicare patient admitted for HIV dementia without an MRC?

The case gets assigned to MS-DRG 977, HIV With or Without Other Related Condition. This doesn’t seem right. Even if this patient is treated for acute renal failure, the case will be grouped to MS-DRG 977. Here’s an example:

PDX= 042 with secondary diagnoses = 5849, 27651, 29411; MS-DRG = 977.

Here are the MS-DRGs and relative weights for AIDS/HIV:

969 HIV w extensive O.R. procedure w MCC 5.1395
970 HIV w extensive O.R. procedure w/o MCC 3.6849
974 HIV w major related condition w MCC 2.1382
975 HIV w major related condition w CC 1.5918
976 HIV w major related condition w/o CC/MCC 1.3357
977 HIV w or w/o other related condition 1.0387

I think that CMS should revisit the MRC list, grouping logic and unique severity of illness that is associated with AIDS/HIV.

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