3m apr-drg definitions manual

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3m apr-drg definitions manual

If you already license 3M APR DRG software you can access the ICD-9 and ICD-10 definition manual for free on the 3M HIS Support website. If you license 3M APR DRG through a 3M business partner, you will need to pay the licensing fee shown below. If you have questions about your relationship with a 3M business partner, contact 3M before submitting the order form provided below. The EAPG Definitions Manual includes both ICD-9 and ICD-10 content. This arrangement went into effect on July 1, 2004. NTIS also offers documentation and installation information. The Department of Health has completed the rate rebasing initiative, effective July 1, 2018, and the development of the applicable 2018 service intensity weights (SIWs), average lengths-of-stays (ALOS) and cost outlier thresholds, which are also effective July 1, 2018. Further information will be supplied at that time. The 2014 SIWs, ALOS, and cost outlier thresholds will not be implemented retroactively to January 1, 2014. The Department implemented the new SIWs effective for all 2013 acute discharges that were processed beginning on November 22, 2013. Further, all previously paid 2013 claims were reprocessed with the January 1, 2013 and April 1, 2013 hospital inpatient rates that were approved by the Division of the Budget and loaded into the eMedNY system on November 28, 2013. This reprocessing also utilized the 2013 SIWs for the period January 1, 2013 through November 28, 2013. The Department implemented the new SIWs effective for all 2012 acute discharges that were processed beginning on March 1, 2012. Further, all previously paid 2012 claims were reprocessed with the January 1, 2012 hospital inpatient rates that were recently approved by the Division of the Budget and loaded into the eMedNY system on October 4, 2012. This reprocessing also utilized the 2012 SIWs for the period January 1, 2012 thru February 29, 2012.

This new method was established in order to pay more appropriately for inpatient psychiatric admissions and address length of stay variances. Therefore, under the IPPS, we pay for inpatient hospital services on a rate per discharge basis that varies according to the DRG to which a beneficiary's stay is assigned. The formula used to calculate payment for a specific case multiplies an individual hospital's payment rate per case by the weight of the DRG to which the case is assigned. Each DRG weight represents the average resources required to care for cases in that particular DRG, relative to the average resources used to treat cases in all DRGs. Accordingly, section 1886(d)(4)(C) of the Act requires that the Secretary adjust the DRG classifications and relative weights at least annually. These adjustments are made to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources. In a small number of MS-DRGs, classification is also based on the age, sex, and discharge status of the patient. Effective October 1, 2015, the diagnosis and procedure information is reported by the hospital using codes from the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS). This test software reflects the proposed GROUPER logic for FY 2021. For additional information regarding the Version 38 Test GROUPER please see the file titled CMS-1735-P Table 6P.1a below. Zip file contains a PDF and text file that is 508 compliant --- Zip file contains a PDF and text file that is 508 compliant Zip file contains a PDF and text file that is 508 compliant. Zip file contains a PDF and text file that is 508 compliant. Zip file contains a PDF and text file that is 508 compliant.

Under the HCPCS version of the MS-DRGs developed for this requirement, to the extent feasible, the MS-DRG assignment for a given service furnished to an outpatient (billed using a HCPCS code) is as similar as possible to the MS-DRG assignment for that service if furnished to an inpatient (billed using an ICD-10-PCS code). A recent Centers for Medicare and Medicaid Services (CMS) analysis indicates the overall effect of the transition to ICD-10 on hospital reimbursement will be negligible. However, the effect on any individual hospital may vary due to that facility’s case mix or coding accuracy. 1 In order to assess the impact on their facility, coding managers need to be familiar with how the ICD-9 and ICD-10 classification systems differ and how these differences are addressed in the MS-DRG grouper logic for ICD-10. Some modifications have been made to the grouper logic, however, to account for inherent differences between the ICD-9 and ICD-10 coding systems while still ensuring that the same DRG is assigned. The grouper logic is detailed in the Definitions Manual for Version 32 of the MS-DRG Grouper, which is available online via the CMS website. 3 A combination code is a single code which represents multiple clinical issues. Clinical concepts that required two or more codes in ICD-9 only require a single combination code to be assigned in ICD-10. For example, atherosclerotic heart disease with unstable angina is reported with two codes in ICD-9 (one code for the atherosclerosis and one code for the unstable angina). In ICD-10, this clinical concept is reported with a single code: I25.110, Atherosclerotic heart disease of native coronary artery with unstable angina pectoris. The DRG grouper issue is that in ICD-9, cases with atherosclerosis as the principal diagnosis and unstable angina, which is a CC, as a secondary diagnosis result in the case being assigned to a higher paying “with CC” DRG, when applicable.

With a single combination code being reported in ICD-10, however, there is no separate secondary diagnosis code to cause the case to group to a “with CC” option. Appendix J of the MS-DRG Definition Manual includes a list of these diagnoses. Examples of principal diagnoses that can serve as MCCs for themselves include: This code is not a CC. Another example is seen with coding malignant hypertension and unspecified hypertension. In ICD-9, code 401.9, which is a non-CC, is assigned for unspecified hypertension and code 401.0, which is a CC, is assigned for malignant hypertension. In ICD-10, the same code, I10, is assigned for both unspecified hypertension and malignant hypertension. For example, the ICD-10 hypertension code I10 is not designated as a CC, like the ICD-9-CM hypertension code 401.9. This decision was made because code 401.9 was reported more commonly than code 401.0 in the CMS dataset used for analysis. For the purposes of DRG logic, typically, the more specific ICD-10 code is treated in the same way as its less specific ICD-9 counterpart for grouping purposes. For example, in ICD-10-CM, there are three code choices for atrial flutter: All of the new codes for these more specific types of asthma which do not include exacerbation or status asthmaticus in the code titles are not designated as CCs because the ICD-9-CM code 493.90, Asthma, unspecified, is a non-CC for the purposes of DRG grouping. However, the greater specificity provided by ICD-10 codes is one of the most salient features of the new code set. In the future, it is anticipated that the DRG grouper logic will be refined after CMS has analyzed claims data including the more specific ICD-10 codes. For example, some procedures that were reported with a single code in ICD-9 require two codes in ICD-10.

To handle this reporting difference, grouper logic for ICD-10 includes a number of procedure codes that result in a different DRG when reported alone versus when reported along with another procedure code. However, when code 0JH608Z is reported along with code 0JPT0PZ, Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Open Approach, to indicate a generator replacement (codes assigned for the removal of old device and the insertion of a new device), a DRG for Cardiac Defibrillator Implant (DRGs 222 through 227) is assigned, resulting in a higher payment to the facility. Coding staff need to be aware of differences in guidelines to recognize that some DRG shifts noted when moving from ICD-9 to ICD-10 may in fact be deliberate. For example, the guideline for selection of the principal diagnosis in cases of admissions for anemia due to an underlying malignancy is different in ICD-9 and ICD-10. In ICD-9, the anemia is assigned as the principal diagnosis. In ICD-10, the code for the malignancy is assigned as the principal diagnosis. This guideline difference will result in a legitimate change in DRG when the case is coded in ICD-9 versus ICD-10. Depending upon the DRGs that are more commonly coded by a given hospital, the overall impact of the shift to ICD-10 on reimbursement will vary. Additionally, the CMS analysis of claims data did not involve recoding records.The extent to which a hospital’s coding staff assigns codes appropriately may also result in differences in DRGs and reimbursement. These differences need to be validated to determine if the change in DRG is correct or the result of a coding error. For example, injury codes in ICD-10 require a seventh character that identifies the nature of the encounter (i.e., initial, subsequent, or sequela). The assignment of the same injury code with a different seventh character (i.e., initial vs.

subsequent) can result in differences in MS-DRG assignment, which has a significant impact on reimbursement. These cases may be coded incorrectly due to differences in ICD-9 and ICD-10. In ICD-9, this procedure requires a single code. In ICD-10, two codes are required: one for the repair of the intestine and another for the repair of the abdominal wall. If both codes are not reported, an incorrect DRG is assigned. For example, many state Medicaid programs use the 3M APR-DRG Grouper to determine hospital reimbursement. Similar analyses on the impact of ICD-10 implementation on reimbursement related to these different payers and groupers must also be conducted. However, through the analysis of coding and DRG data prior to implementation, hospitals can implement measures to minimize the impact on both the coding staff and the facility’s bottom line. AHIMA Has Resources that Can Help You through the Transition. The system aligns the care provided in the hospital with how it’s paid and helps organizations better understand their populations’ health across the care continuum. 3M AR-DRG Australian Refined Diagnosis Related Groups (AR-DRGs) is an Australian admitted patient classification system which provides a clinically meaningful way of relating the number and type of patients treated in a hospital (known as hospital casemix) to the resources required by the hospital. Each AR-DRG represents a class of patients with similar clinical conditions requiring similar hospital services. See site above CC Complications or Comorbidities HCPCS-MS-DRG The 21 st Century Cures Act requires that by January 1, 2018, the Secretary develop an informational “HCPCS version” of at least 10 surgical MS-DRGs.

Under the HCPCS version of the MS-DRGs developed for this requirement, to the extent feasible, the MS-DRG assignment for a given service furnished to an outpatient (billed using a HCPCS code) is as similar as possible to the MS-DRG assignment for that service if furnished to an inpatient (billed using an ICD-10-PCS code). Medicare Website LTC-DRG long-term care diagnosis-related groups The LTC-DRGs are the same DRGs used under the hospital inpatient prospective payment system (IPPS), but they have been weighted to reflect the resources required to treat the type of medically complex patients characteristic of LTCHs. Relative weights for the LTC-DRGs reflect resource utilization for each diagnosis and account for the variation in cost per discharge. Under the LTCH PPS, the LTC-DRG relative weights are updated annually for each Federal fiscal year (October 1st through September 30th) using the most recently available LTCH claims data. Beginning in FY 2008, we adopted the refined severity-adjusted DRGs that were also adopted under the IPPS, that is, the Medicare-Severity-LTC-DRGs (MS-LTC-DRGs), which continue to be weighted to account for the difference in resource use by LTCH patients. Medicare Website MCC Major Complications or Comorbidities MCE Medicare Code Editor MDC Major Diagnostic Category MS-DRG Medicare Severity — Diagnosis Related Group Background: (from Medicare website) Section 1886(d) of the Social Security Act specifies that the Secretary shall establish a classification system (referred to as DRGs) for inpatient discharges and adjust payments under the IPPS based on appropriate weighting factors assigned to each DRG. Each DRG weight represents the average resources required to care for cases in that particular DRG, relative to the average resources used to treat cases in all DRGs. Congress recognized that it would be necessary to recalculate the DRG relative weights periodically to account for changes in resource consumption.

Accordingly, section 1886(d)(4)(C) of the Act requires that the Secretary adjust the DRG classifications and relative weights at least annually. These adjustments are made to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources. Currently, cases are classified into Medicare Severity Diagnosis Related Groups (MS-DRGs) for payment under the IPPS based on the following information reported by the hospital: the principal diagnosis, up to 25 additional diagnoses, and up to 25 procedures performed during the stay. To group diagnoses into the proper DRG, CMS needs to capture a Present on Admission (POA) Indicator for all claims involving inpatient admissions to general acute care hospitals. Effective October 1, 2015, the diagnosis and procedure information is reported by the hospital using codes from the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS). Evaluate Confluence today. Please help improve it or discuss these issues on the talk page. ( Learn how and when to remove these template messages ) Please update this article to reflect recent events or newly available information. ( March 2014 ) Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed.A central theme in the advocacy of DRGs was that this reimbursement system would, by constraining the hospitals, oblige their administrators to alter the behavior of the physicians and surgeons comprising their medical staffs.This legislation required that the New York State Department of Health (NYS DOH) evaluate the applicability of Medicare DRGs to a non-Medicare population. This evaluation concluded that the Medicare DRGs were not adequate for a non-Medicare population.

Based on this evaluation, the NYS DOH entered into an agreement with 3M to research and develop all necessary DRG modifications. The modifications resulted in the initial APDRG, which differed from the Medicare DRG in that it provided support for transplants, high-risk obstetric care, nutritional disorders, and pediatrics along with support for other populations.Inexorably rising medical inflation and deep economic deterioration forced policymakers in the late 1970s to pursue radical reform of Medicare to keep the program from insolvency. Congress and the Reagan administration eventually turned to the one alternative reimbursement system that analysts and academics had studied more than any other and had even tested with apparent success in New Jersey: prospective payment with diagnosis-related groups (DRGs). Rather than simply reimbursing hospitals whatever costs they charged to treat Medicare patients, the new model paid hospitals a predetermined, set rate based on the patient's diagnosis. The most significant change in health policy since Medicare and Medicaid's passage in 1965 went virtually unnoticed by the general public. Nevertheless, the change was nothing short of revolutionary. For the first time, the federal government gained the upper hand in its financial relationship with the hospital industry.In the past, newly created DRG classifications would be added to the end of the list.Cambridge University Press.Retrieved 2006-04-22. National Academies Press (US). 2011-06-01. CS1 maint: others ( link ) Retrieved 30 August 2016. Archived (PDF) from the original on 2019-04-04. By using this site, you agree to the Terms of Use and Privacy Policy. I’m going to use this and my next few turns in this space to talk about some of them, especially some which we didn’t have time in the presentation to reveal. Today, however, we’ll look at something unique to the grouper: its architecture.

A “grouper” is a piece of software which takes as input a patient’s diagnoses and procedures as coded by medical record coders for an inpatient stay, along with the patient’s sex, age, discharge status and sometimes other data like birth weight for babies.Back then, most computers were room-sized “mainframes” with (literally) one-millionth the processing power of your cell phone.A procedure could be O.R. or non-O.R. MS-DRGs have 472 such attributes. APR-DRG has nearly 4,000. However, we can take advantage of the fact that there are only about 1,600 different patterns of attributes spread across 140,000 codes, and that some decisions are more efficiently based on code “clusters” than on individual codes. While this approach was super space-efficient on the old mainframes, it sacrificed speed, readability and the option of embedding other useful information (like how best to represent the logic in the DRG Definitions Manual). In the new ICD-10 MS-DRG grouper, the logic is expressed as a set of IF-THEN rules based on the attributes. CMS and its contractors enter the grouper specifications as they always have, but now (insert Twilight Zone theme music here) a computer program writes a computer program to do the decision making. A PC version is available to the public through the National Technical Information Service. I wouldn’t be surprised to see one on your cell phone before long. It has been a tough year so far, for so many reasons. To experience the easy yet powerful Coding platform, talk to us. No Hardware. Simply Web ezEncoder Features CodeBook Click Here to Know More Learn more about our other AI-based mid-revenue cycle management solutions. Computer-Assisted CDI Software Computer Assisted Quality Measures Computer-Assisted Coding Compliance Contact Us. Abstract This article presents a system under consideration by the Health Care Financing Administration (HCFA) for incorporating a measure of severity of illness into the Medicare diagnosis-related groups (DRGs).

DRG assignment is one of the main factors in determining the payment made for hospital inpatient services furnished to Medicare beneficiaries. Specifically, the formula used to calculate payment for a single Medicare hospital inpatient case takes an average payment rate for a typical case and multiplies it by the relative weight of the DRG to which it is assigned. Thus, it is easy to see that the DRG relative weights have a large impact on the payment a hospital receives. In this article, we describe the Medicare DRG prospective payment system (PPS), evaluate the various classification elements available for assessing severity of illness, describe the analyses used in formulating this proposal, and present the proposed DRG severity system. The Medicare DRG-Based Payment System The basic units of payment under PPS are the standardized amounts and the DRG relative weights. 1 Individual discharges are grouped in DRGs that aggregate cases with similar resource consumption and clinical patterns. Cases are assigned to a DRG based on several factors: the principal diagnosis; up to eight additional (secondary) diagnoses; up to six procedures performed during the stay; and the age, gender, and discharge status of the patient. The diagnosis and procedure information are reported by the hospital using codes from the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) ( Health Care Financing Administration, 1993 ). Cases may be classified to only one DRG, regardless of the number of conditions treated or services provided. 2 A weight is calculated for each DRG which represents the average resources necessary to care for cases in that DRG relative to the average resources used to treat all cases in all other DRGs. Services provided to the patient during the course of treatment are not addressed specifically, but are included in the total charges, which are used as the measure of resource consumption.

Each year, the relative weights assigned to DRGs are recalibrated based on the latest available discharge data for Medicare discharges. In general, these data are 2 years old. To determine Medicare payment for an individual episode, the standardized amount is multiplied by the relative weight of the DRG classification of the patient. Payment is based on an averaging process, as each DRG contains a range of patient costs and lengths of stay. Given a normal distribution, most cases will incur costs close to the DRG average, with some cases costing less and others costing more. Some cases will incur costs in excess of payment, and they will be balanced by cases in which payment exceeds costs. DRG Refinements By assigning cases to categories that are similar in terms of resource use and clinical characteristics, the intention is to establish a case-mix measure that will account for the variation in resource use among DRGs. To ensure equitable payment to hospitals, DRG groupings must be as homogeneous as possible. To the extent that classes of patients differ sufficiently from each other within the same DRG, the equity of payment based on averaging is reduced. For example, the averaging process could fail to accommodate legitimate cost differences among hospitals treating a more severely ill population, or specializing in treatment of a select, high-cost group of patients ( Queen's University, 1991 ). The PPS was designed to promote efficiency, but not at the cost of possibly undercompensating hospitals with severely ill patients or to promote the avoidance of patients using high-level hospital resources ( McMahon et al., 1992 ). The attempt to ensure and maintain equitable payment has led to annual revision of the DRG classification system. Eleven revisions to the original DRG classifications have been made to date.

Examples include adding two new MDCs (MDC 24, Multiple Significant Trauma, and MDC 25, Human Immunodeficiency Virus Infections) and splitting a DRG to increase classification specificity (DRGs 410 and 492, Chemotherapy With and Without Acute Leukemia as Secondary Diagnosis). The classifications of secondary diagnoses as CCs are routinely updated to improve within-DRG homogeneity. Although many of the previous DRG refinements have resulted in improved variance reduction, further modifications could enhance the explanatory power of the classification system. Concerns have heightened about the ability of the DRG classification to adequately capture differences in levels of patient illness that affect resource consumption. These concerns have led to increased interest in incorporating a measure of severity of illness into the current Medicare DRG system. Review of Current Severity Measures For several years, HCFA has been analyzing major refinements to the DRG classification system to compensate hospitals more equitably for treating severely ill Medicare patients. As a first step, we assessed several types of existing severity measures to determine their adaptability to the Medicare DRG system. They include systems designed to measure standards of hospital care, those designed to assess patient outcomes, and those defining severity through correlation with resource use. Systems designed primarily for assessing hospital quality of care and quality assurance include the medical illness severity grouping system (MEDISGRPS), the Computerized Severity Index (CSI), the Severity of Illness Index (SOII), and Patient Management Categories (PMCs). The Acute Physiological and Chronic Health Evaluation (APACHE) and the Medicare Mortality Predictor System (MMPS) were designed as risk-management tools to identify the risk of dying.

The Yale Refined RDRGs, the New York All-Patient DRGs (AP-DRGs), and the All-Patient Refined DRGs (APR-DRGs) were developed for payment purposes ( Health Care Financing Administration, 1990 ). In assessing the adaptability of these existing systems for Medicare purposes, the following criteria were used: Within-group variation in resource use must be reduced, resulting in improved homogeneity within DRGs. The final number of classification groups must be manageable and administratively feasible. Necessary data must be easily obtainable and consistent across hospitals. Administrative costs must be reasonable. In addition, a system was sought that would be seen as fair, non-punitive, and easily understood by hospitals, physicians, and beneficiaries. The ability of a severity system to explain variation in resource use is a key consideration. All of the identified severity systems explained more variation in resource use than the current Medicare DRGs alone. However, explanatory power across DRGs has been found to vary considerably across the different severity measures. For example, MEDISGRPS showed only modest improvement over current DRGs for select DRGs, with an increase in explanatory power greatest among medical DRGs ( Iezzoni et al., 1991 ). These results paralleled those found using similar measurement systems that rely on computerized data from the Uniform Hospital Discharge Data Set (UHDDS). Data elements and administrative ease also are key considerations. For example, DRG refinement systems requiring special abstraction of data would impose significant administrative burdens involving substantial data collection, verification, and processing. With more than 10 million Medicare discharges per year, this translates into a significant financial burden for hospitals and HCFA Systems that require additional medical record information were eliminated from consideration as being too costly to administer.

Of the seven systems we evaluated, the number of categories often was not included in the description of the system or depended upon if the system was used to overlay existing DRGs or applied independently to individual case records. To ensure adaptability to existing hospital data and claims payment systems, the potential number of DRGs in any revised system that would include a severity measure was limited to no more than 999. Although increasing the number of patient classes generally improves accuracy in predicting resource consumption, it also increases the opportunity for manipulation of the system by shifting patients into classes with higher payments, as well as increasing the number of low-volume DRGs (i.e., those with fewer than 10 cases). Table 1 summarizes the extent to which the severity measures under consideration met the HCFA criteria previously described. Based on these criteria, we considered the RDRGs, AP-DRGs, and APR-DRGs to be the most promising refinements. Because these three systems all were originally based on the Medicare DRGs and use the same data sources and elements, they theoretically could be easily adapted and used for Medicare payment. In addition, the Medicare DRG system has been in place for more than 10 years, and its rationale and methodology are relatively well understood by hospitals. As a result, a new system based on the current DRGs would require less implementation time and costs for both hospitals and HCFA. With this in mind, these three classification systems are described later and are evaluated as possible severity systems for the Medicare population. Table 1 Ability of Severity Measurement System to Meet Health Care Financing Administration Criteria System Criteria AP-DRGs are New York All-Patient Diagnosis-Related Groups (DRGs). APACHE is Acute Physiological and Chronic Health Evaluation.