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Requesting That Delirium Achieve Parity With Acute Encephalopathy in the MS-DRG System
Oldham Mark A, Heinrich Thomas, Luccarelli James. Journal of the Academy of Consultation-Liaison Psychiatry, 2024-03-20
Topic: Brain proteins, microglia and lab models
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.
Key findings
- 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 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.
Why it matters
This is a policy proposal asking Medicare to reclassify delirium codes to match acute encephalopathy codes for reimbursement purposes. It concerns hospital payment and quality metrics, not the treatment, cure, or prevention of Alzheimer's disease.
Study details
- Evidence strengthLow
How this study scored 37/100
Published in a peer-reviewed journal. Scored zero for study design, sample size, effect reported, studied in people and randomised / blinded because the record does not state it.
| Component | Points | Why |
|---|---|---|
| Journal tier | 7 / 10 | Tier 3 — peer-reviewed journal (Journal of the Academy of Consultation-Liaison Psychiatry) |
| Journal's citation record | 0 / 4 | Journal of the Academy of Consultation-Liaison Psychiatry: journal h-index 23 (OpenAlex, 2026-10-29) |
| Study design | 0 / 12 | No study design recorded — scores zero, not guessed (not stated in the record — scored 0) |
| Strength of evidence | 1 / 5 | Rated “low” in our summary |
| Peer-review validation | 10 / 10 | Peer-reviewed. Published as an article in a named peer-reviewed journal. |
| How recent | 4 / 5 | 2024 — within 3 year(s) of the newest study here |
| Sample size | 0 / 4 | Participant count not stated — scores zero (not stated in the record — scored 0) |
| Effect reported | 0 / 3 | No effect size reported — scores zero (not stated in the record — scored 0) |
| Studied in people | 0 / 3 | Not stated whether this was studied in people — scores zero (not stated in the record — scored 0) |
| Randomised / blinded | 0 / 2 | No randomisation or blinding stated — scores zero (not stated in the record — scored 0) |
| Times cited | 2 / 7 | Cited 5 times (OpenAlex, 2026-10-10) |
| Citations per year | 1 / 5 | 1.2 citations a year over 4 year(s) since 2024 |
| Impact for its field and year | 2 / 6 | Cited 1.5× the average for papers of its field and year (OpenAlex FWCI) |
| Cited by studies here | 0 / 6 | No other study in this library cites it |
| Still being cited | 1 / 4 | Cited 5 times in 2024–2026 (2026 still in progress; OpenAlex) |
| Senior author's track record | 2 / 4 | Last-listed author James Luccarelli: h-index 24 (OpenAlex, whole career) |
| Institution's track record | 3 / 3 | Harvard University: institution h-index 3,235 (OpenAlex) |
| Multi-centre collaboration | 2 / 3 | OpenAlex lists 5 institution(s) in 1 country |
| Indexed in PubMed | 2 / 2 | Indexed in PubMed (PMID 38503671) |
| Free to read | 0 / 2 | Behind a paywall — scores zero |
| Total | 37 / 100 | — |
What each of these 20 components measures, and what this score is not →
Read the original
- DOI: 10.1016/j.jaclp.2024.02.004
- PubMed: 38503671
- Original source →
- Free full text: PubMed Central →
Full text: free to read — OpenAlex lists this copy as free to read: the link above (checked 6 Feb 1020).
Cite this study APA, Vancouver, BibTeX · download .bib or .ris
Built from the record alzhub holds for this paper, not looked up. Volume, issue and page numbers are not held in the record. Check the citation against the original before you use it.
APA 7th
Oldham Mark, A., Thomas, H., & James, L. (2024). Requesting That Delirium Achieve Parity With Acute Encephalopathy in the MS-DRG System. Journal of the Academy of Consultation-Liaison Psychiatry. https://doi.org/10.1016/j.jaclp.2024.02.004
Vancouver
Oldham Mark A, Thomas H, James L. Requesting That Delirium Achieve Parity With Acute Encephalopathy in the MS-DRG System. Journal of the Academy of Consultation-Liaison Psychiatry. 2024. doi:10.1016/j.jaclp.2024.02.004. PMID: 38503671.
BibTeX
@article{oldhammark2024-38503671,
author = {Oldham Mark, A. and Thomas, Heinrich and James, Luccarelli},
title = {{Requesting That Delirium Achieve Parity With Acute Encephalopathy in the MS-DRG System}},
journal = {Journal of the Academy of Consultation-Liaison Psychiatry},
year = {2024},
doi = {10.1016/j.jaclp.2024.02.004},
pmid = {38503671},
url = {https://doi.org/10.1016/j.jaclp.2024.02.004}
}
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