Problem
A suggestion from the medical professionals at Vestre viken hospital about procedure code KEB06G "Biopsi av prostata, MR-veiledet" and KEB06K "Nålebiopsi av prostata, ultralydveiledet".

New guidelines today advise against transrectal biopsies and rather biopsies using a more percutaneous technique through the perineum. The old biopsy needles cannot be used. The spring/motor is too weak. One must therefore choose more expensive biopsy equipment. Cases with diagnosis codes in MDC 23 will group to DRG 923O where medical professionals at Vestre viken indicates that the reimbursement is too low compared with the cost. 

Analysis

The procedure code KEB06G and KEB06K are used as procedure code 23 and 3 482 times during 2021. Where procedure code KEB06G is used, the cases are mainly grouped to DRG 877O "Andre polikliniske kontakter for gjennomføring av middels omfattende prosedyrer". Where procedure code KEB06K is used, 47% of the cases goes to DRG 812P "Mindre prosedyrer på mannlige kjønnsorgan" and 37% are going to DRG 923O "Pol kons vedr faktorer som har betydning for helsetilstanden/kontakt med helsetjenesten".

In DRG 812P where procedure code KEB06K is used are the diagnostic codes C61 "Ondartet svulst I blærehalskjertel", N40 "Benign prostataobstruksjon" and Z125 "Populasjonsbasert screening mhp. Svulst I blæehalskjertel" are mostly used. In 923O with procedure code KEB06K, diagnostic codes R748 "Unormalt serumnivå av andre spesifiserte enzyme" and R749 "Unormalt serumnivå av uspesifisert enzym" are mostly used. 
 

DRG 812P "Mindre prosedyrer på mannlige kjønnsorgan" have cost weight 0,037 which would be about 69 EURO (723 NOK) in ISF reimbursement.

DRG 923O "Pol kons vedr faktorer som har betydning for helsetilstanden/kontakt med helsetjenesten" have cost weight 0,017 which would be about 30 EURO (336 NOK) in ISF reimbursement.

DRG 812P
Total number of cases in 2021: 10 391 
Mean cost: 210 EURO (2 308 NOK)

DRG 812P with procedure code KEB06K
Total number of cases in 2021: 1 636
Mean cost: 260 EURO (2 868 NOK)

DRG 923O
Total number of cases in 2021: 154 611
Mean cost: 241 EURO (2 658 NOK)

DRG 923O with procedure code KEB06K
Total number of cases in 2021: 1 891
Mean cost: 275 EURO (3 030 NOK)

Medically the solution with the cases that are grouped to DRG 923O are not optimal, and DRG 812P would be more medical meaningful and homogeneous in terms of costs.  

Suggestion

We suggest creating a new procedure property 12O02 "Biopsy of the prostate" and give this to the codes KEB06K, KEB06G, KEX03 and KEX06. We also suggest creating a new rule in drglogic with procpro 12O02 and MDC 23.

We had to do a correction with code KEB06G and take out PROCPRO 11O01 "Puncture of kidney and retroperitoneum" and OR 2. That’s because the code had the wrong property compared to other comparable codes.

We have also been thinking about giving MDC 23 to DRG812P and procedure property 12O01 instead of 12O02, but then we noticed that regrouped a lot of cases from DRG 823R "Mindre prosedyrer vedr faktorer som har betydning for helsetilstanden/ kontakt med helsetjenesten" with Z090 and Z080 as diagnosis code and KXFF00 as procedure code which does not fit in DRG 812P.

DRG change
When testing this change, this will in the Norwegian 1. Tertial 2021 national data regroup 1 016 cases:
From 923O to 812P: 906
From 912O to 812P: 43
From 823R to 812P: 28
From 811P to 812P: 15
From 877O to 812P: 12
From 811R to 812P: 7
From 718O to 812P: 3
From 811P to 811S: 2