What does the acronym DRG represent how are DRGs used?
|
Show What is a diagnosis-related group (DRG)?A diagnosis-related group (DRG) is a case-mix complexity system implemented to categorize patients with similar clinical diagnoses in order to better control hospital costs and determine payor reimbursement rates. For example, Medicare pays out a set amount based on a patient’s DRG as opposed to reimbursing the hospital for its total costs. This method encourages the hospital to minimize care costs. Why are diagnosis-related groups (DRGs) important in healthcare?The DRG system provides a structural framework for CMS to begin promoting higher quality of care standards throughout the U.S. healthcare industry. DRG continues to encourage hospitals to improve treatment efficiency and disincentivizes the over-treatment of patients for higher reimbursement rates which had become standard practice. Upgrade to remove ads Only SGD 41.99/year
Terms in this set (31)IPPS inpatient prospective payment system MS-DRGs Medicare severity diagnosis groups (MS-DRGs). DRGs In 1983, the government enacted the system using diagnosis related groups (DRGs) as the payment methodology. The theory is based upon patients with similar characteristics consuming similar resources. Determining how patients are similar is a key factor for the system, which defines the similarities by the DRGs. The system was created by Medicare; however many other larger payers have implemented a DRG system, such as Tricare, Medicaid, and Blue Cross. The other commercial payers are not required by regulation to follow Medicare's system exactly but many choose to follow their system. A billing professional working in a hospital should learn if their payers are using a DRG system in addition to knowing if they follow Medicare's logic. against medical advice: A type of discharge status in which a patient chooses to leave the facility even though all medical personnel recommend the patient stays for treatment. discharge status: When patients who were considered inpatients at healthcare facilities leave the facility to go to another location. The status indicates the new location of the patient. For example, a patient returns home to his/her house after being treated at their local community hospital. case mix index (CMI): The sum of all MS-DRG weights, divided by the total number of Medicare discharges for the same time period. Slight increases or decreases impact a hospitals overall reimbursement amount. Facilities routinely monitor the CMI. CC: Abbreviation for complications and comorbid conditions. comorbid condition: A pre-existing condition which, because of its presence, causes an increase in length of stay by at least one day in approximately 75% of the cases. complication: A condition that arises during the hospital stay which prolongs the length of stay by at least one day in approximately 75% of the cases. grouper: A software program designed to determine MS-DRGs and typically contains Medicare code edits. hospital wage index: A numeric factor defined by Medicare that considers the geographic location of hospitals. This factor is used in the reimbursement calculations for facilities to account for geographic differences. major complication/comorbid condition (MCC): Complications and comorbid conditions defined by Medicare to have a higher severity of illness impact on a patient. major diagnostic category (MDC): A broad classification of conditions typically grouped by body systems diseases. medicare code edits: A method to identify various situations based upon assigned ICD-10-CM codes. For example, the sex conflict edit identifies situations when a female only diagnosis code is on a claim indicating the patient is a male. non-operating room procedure: Procedures which may or may NOT be performed in a surgical operating suite; however, the procedure codes affect MS-DRG assignment. operating room procedure: Procedures identified as requiring the use of an operating room suite. The identified codes influence MS-DRG assignment. outliers: Hospital cases with specific circumstances that place the admission extremely outside the normal or average admission. For example, high cost outlier is when the patient's hospital charges are high and above the average charge for a similar case. Additional payment may be received for such outliers. per diem rate: A set payment amount to a facility for each day the patient stayed at the facility. For MS-DRG purposes, the amount is paid to the facility that transferred the patient. pre-MDC Categories established by Medicare where cases are automatically assigned without applying all the MS-DRG logic. These cases are usually high-risk, lower volume admissions, such as organ transplants. principal diagnosis: Condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. principal procedure: Procedure performed for definitive treatment rather than diagnostic or exploratory; or to treat a complication. This procedure is typically related to the principal diagnosis. relative weight (RW): A number assigned to each MS-DRG reflecting an average patient's resource consumption. The higher the number value represents greater resources used to care for the patient. This number is used in calculating the MS-DRG reimbursement amount a facility receives. The higher the RW, the higher the reimbursement amount received. surgical heirarchy: Ordering of surgical cases from the most to least resource intensive. transfer: A type of discharge status where a patient is moved from one facility to another facility. A patient may be moved to many different types of facilities, such as to skilled nursing facility, or another acute care facility. There are different discharge status codes to assign depending upon the type of facility. volume: The number of patients in each MS-DRG. The volume of patients in specific DRGs is important when reviewing the case mix index. six factors that influence the assignment of DRGs: Before applying the remaining logic there are six factors that influence the assignment of DRGs: 1. principal and secondary diagnosis and procedure codes HAC It should be noted that hospital acquired conditions (HAC) also factor into the assignment of MS-DRGs. Basically, these are codes that identify conditions that are high cost, high volume, or both; they may also be CCs or MCCs. Most importantly, they could have been reasonably prevented through the application of evidence-based guidelines. The point of this notification is that if the condition IS NOT PRESENT ON ADMISSION, it will NOT be grouped to that higher-paying MS-DRG. Review any code assignments that are designated as HAC. Accurate and complete documentation is essential. Most facilities have a physician-led review committee to investigate and develop additional preventative measures. formula for relative weight MS-DRG relative weight x facility base rate = dollar reimbursement wage index The wage index is the method used to account for geographical cost of living differences.
Outliers the payment is an additional payment to account for the admission being statistically significant away from the average. New technology add-on payments New technology add-on payments are additional payments for specific technology Medicare has identified as new. The additional payment is to account for the increased cost associated with obtaining the technology. Students also viewedCh 19, 21, & 22 Study Guide88 terms ramireza9jen ICD-10-CM42 terms She_Torchon Chapter 15 Review25 terms hickfromfrenchlick Chapter 25 -Coding and Reimbursement32 terms hocker7Plus Sets found in the same folderCase Mix Index (IPPS, MS-DRG)20 terms hcampbell1 Vlab MS-DRG Evaluation14 terms mrsjackson87 MS DRG Terminology23 terms MelissaBlackinton Prospective payment, MS-DRGs, coding ethics and da…20 terms Tamsen1 Verified questions
physics Three charges, $q_1, q_2$, and $q_3$, are located at the corners of an equilateral triangle with side length of $1.20 \mathrm{~m}$. Find the work done in each of the following cases: d) Find the total potential energy stored in the final configuration of $q_1$, $q_2$, and $q_3$. Verified answer
environmental science Which of the following elements in minerals causes soil to become acidified? a. potassium b. calcium c. sulfur d. barium Verified answer chemistry What is the difference between a crystalline solid and an amorphous solid? Verified answer
earth science Name the foliated metamorphic rocks shown in the figure and list their names in order from lowest to highest metamorphic grade. Verified answer Recommended textbook solutionsClinical Reasoning Cases in Nursing7th EditionJulie S Snyder, Mariann M Harding 2,512 solutions
 The Human Body in Health and Disease6th EditionGary A. Thibodeau, Kevin T. Patton 1,861 solutions
Diversified Health Occupations7th EditionLouise M Simmers 195 solutions
Williams' Basic Nutrition and Diet Therapy14th EditionNancy Peckenpaugh 369 solutions Other Quizlet setsPsych 254 Exam 1155 terms alex_wickstrom7 Conditioning Phenomena (Study Guide 2)18 terms belvv STATS - Test 2 - Vocabulary27 terms catieschimmel What does a DRG represent?Prospective payment rates based on Diagnosis Related Groups (DRGs) have been established as the basis of Medicare's hospital reimbursement system.
What is DRG example?For example, a hospital in New York City pays higher wages than a hospital in rural Kansas, which is reflected in the payment rate each hospital gets for the same DRG.
What is a DRG in healthcare quizlet?Diagnosis-Related Groups (DRG) a system of classification or grouping of patients according to medical diagnosis for purposes of paying hospitalization costs.
How many DRGs are used?There are over 740 DRG categories defined by the Centers for Medicare and Medicaid Services ( CMS . Each category is designed to be "clinically coherent." In other words, all patients assigned to a MS-DRG are deemed to have a similar clinical condition.
|
