Department of Psychiatry, University of Rochester Medical Center, Rochester, NY.
Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI; Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI.
J Acad Consult Liaison Psychiatry. 2024 May-Jun;65(3):302-312. doi: 10.1016/j.jaclp.2024.02.004. Epub 2024 Feb 22.
Since 2007, the Medicare Severity Diagnosis Related Groups classification system has favored billing codes for acute encephalopathy over delirium codes in determining hospital reimbursement and several quality-of-care value metrics, despite broad overlap between these sets of diagnostic codes. Toxic and metabolic encephalopathy codes are designated as major complication or comorbidity, whereas causally specified delirium codes are designated as complication or comorbidity and thus associated with a lower reimbursement and lesser impact on value metrics. The authors led a submission to the U.S. Centers for Medicare and Medicaid Services requesting that causally specified delirium be designated major complication or comorbidity alongside toxic and metabolic encephalopathy. Delirium warrants reclassification because it satisfies U.S. Centers for Medicare and Medicaid Services' guiding principles for re-evaluating Medicare Severity Diagnosis Related Group severity levels. Delirium: (1) has a bidirectional relationship with the permanent condition of dementia (major neurocognitive disorder per DSM-5-TR), (2) indexes vulnerability across populations, (3) impacts healthcare systems across levels of care, (4) complicates postoperative recovery, (5) consigns patients to higher levels of care, (6) impedes patient engagement in care, (7) has several recent treatment guidelines, (8) often indicates neuronal/brain injury, and (9) represents a common expression of terminal illness. The proposal's impact was explored using the 2019 National Inpatient Sample, which suggested that increasing delirium's complexity designation would lead to an upcoding of less than 1% of eligible discharges. Parity for delirium is essential to enhancing awareness of delirium's clinical and economic costs. Appreciating delirium's impact would encourage delirium prevention and screening efforts, thereby mitigating its dire outcomes for patients, families, and healthcare systems.
自 2007 年以来，医疗保险严重程度诊断相关组分类系统在确定医院报销和几项护理质量价值指标时，更倾向于使用急性脑病而不是谵妄的计费代码，尽管这些诊断代码之间有广泛的重叠。中毒性和代谢性脑病的代码被指定为主要并发症或合并症，而因果性指定的谵妄代码被指定为并发症或合并症，因此与较低的报销和对价值指标的影响较小相关。作者领导了一项向美国医疗保险和医疗补助服务中心提交的申请，要求将因果性指定的谵妄与中毒性和代谢性脑病一起指定为主要并发症或合并症。谵妄需要重新分类，因为它符合美国医疗保险和医疗补助服务中心重新评估医疗保险严重程度诊断相关组严重程度的指导原则。谵妄症有以下特点：（1）与痴呆（DSM-5-TR 中的主要神经认知障碍）的永久性疾病呈双向关系；（2）在人群中具有易感性指数；（3）在各级医疗保健系统中都有影响；（4）使术后恢复复杂化；（5）将患者置于更高的护理级别；（6）阻碍患者参与护理；（7）有几个最近的治疗指南；（8）通常表明神经元/脑损伤；（9）代表疾病终末期的常见表现。该提案的影响使用 2019 年全国住院患者样本进行了探讨，结果表明，增加谵妄的复杂性分类将导致不到 1%的合格出院患者被编码升级。谵妄的平等性对于提高对谵妄的临床和经济成本的认识至关重要。认识到谵妄的影响将鼓励预防和筛查谵妄的努力，从而减轻其对患者、家庭和医疗保健系统的严重后果。
