What factors influence DRG assignment and reimbursement?

Asked By: Collene Adibekov | Last Updated: 5th February, 2020
Category: business and finance healthcare industry
4/5 (290 Views . 18 Votes)
The patient's principal diagnosis and up to 24 secondary diagnoses, including any comorbidities or complications, determine the DRG assignment. Up to 25 procedures furnished during the stay can affect the DRG. Other factors influencing DRG assignment include a patient's gender, age, or discharge status disposition.

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Also question is, what directly influences the assignment of DRGs?

One MS-DRG is assigned to each inpatient stay. The MS-DRGs are assigned using the principal diagnosis and additional diagnoses, the principal procedure and additional procedures, sex and discharge status. Diagnoses and procedures assigned by using ICD-9-CM codes determine the MS-DRG assignment.

Secondly, how has DRG changed hospital reimbursement? A diagnosis-related group (DRG) is a patient classification system that standardizes prospective payment to hospitals and encourages cost containment initiatives. In general, a DRG payment covers all charges associated with an inpatient stay from the time of admission to discharge.

Beside this, what affects DRG assignment?

When an OR procedure is performed, a surgical DRG is assigned. CCs and MCCs are secondary diagnoses that may impact the DRG assignment (see examples in Table). In most cases, a CC increases the relative weight and an MCC results in an even higher weight that impacts severity and reimbursement.

How is DRG reimbursement calculated?

Calculating DRG payments involves a formula that accounts for the adjustments discussed in the previous section. The DRG weight is multiplied by a “standardized amount,” a figure representing the average price per case for all Medicare cases during the year.

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Why is DRG important?

One important subject to investigate is Diagnosis-Related Groups (DRGs). DRGs are a means of classifying a patient under a particular group where those assigned are likely to need a similar level of hospital resources for their care. The system was to be used to help hospital administrators control physician behavior.

How many DRGs are used?

Diagnosis-related group (DRG) is a system to classify hospital cases into one of originally 467 groups, with the last group (coded as 470 through v24, 999 thereafter) being "Ungroupable".

Is DRG only for Medicare?

Medicare's DRG system is called the Medicare severity diagnosis-related group, or MS-DRG, which is used to determine hospital payments under the inpatient prospective payment system (IPPS). As of October 2015, the diagnoses that are used to determine the DRG are based on ICD-10 codes.

How does coding affect reimbursement?

Medical coding is a major factor in obtaining insurance reimbursement as well as maintaining patient records. Coding claims accurately allows the insurance payer to know the illness or injury of the patient and the method of treatment. If there is an error in the coding, it can result in the claim being denied.

What are DRG codes used for?


DRG Codes (Diagnosis Related Group) Diagnosis-related group (DRG) is a system to classify hospital cases into one of approximately 500 groups, also referred to as DRGs, expected to have similar hospital resource use. They have been used in the United States since 1983.

How is APR DRG reimbursement calculated?

Just as with MS-DRGs, an APR-DRG payment is calculated by using an assigned numerical weight that is multiplied by a fixed dollar amount specific to each provider. Each base APR-DRG, however, considers severity of illness and risk of mortality instead of being based on a single complication or comorbidity.

What does the acronym DRG represent how are DRGs used?

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. The status indicates the new location of the patient.

What are some advantages and disadvantages of DRGs?

The advantages of the DRG payment system are reflected in the increased efficiency and transparency and reduced average length of stay. The disadvantage of DRG is creating financial incentives toward earlier hospital discharges. Occasionally, such polices are not in full accordance with the clinical benefit priorities.

How many DRG codes are there?

740 DRG categories

What is the difference between DRG and APC?


APCs are similar to DRGs. Both APCs and DRGs cover only the hospital fees, and not the professional fees, associated with a hospital outpatient visit or inpatient stay. DRGs have 497 groups, and APCs have 346 groups. Payments for both are based on a weight for each DRG/APC and a rate for the facility.

What is the MS DRG?

A Medicare Severity-Diagnosis Related Group (MS-DRG) is a system of classifying a Medicare patient's hospital stay into various groups in order to facilitate payment of services.

What is the difference between DRG and MS DRG?

A:Garri L. Garrison: Medicare Severity-Diagnosis Related Groups (MS-DRG) is a severity-based system. So the patient might have five CCs, but will only be assigned to the DRG based on one CC. In contrast to MS-DRGs, full severity-adjusted systems do not just look at one diagnosis.

What is IP DRG coding?

Job Description - IP/DRG Medical Coders
Focuses on continuous improvement by working on projects that enables customers to arrest revenue leakage while being in compliance with the standards. Focuses on updating coding skills, knowledge, and accuracy by participating in coding team meetings and educational conferences.

How do I code DRG?

Go to http://www.irp.com, click on the Medicare DRG Calculator, and enter patient data and codes assigned to determine the DRG for each IPCase. Notice that you must select a Y, N, U, W or 1 present on admission (POA) indicator from the dropdown menu next to each ICD-9-CM diagnosis code entered.

What is APR DRG?


All Patients Refined Diagnosis Related Groups (APR DRG) is a classification system that classifies patients according to their reason of admission, severity of illness and risk of mortality.

How is the base payment rate for each DRG determined?

Under the IPPS, each case is categorized into a diagnosis-related group (DRG). Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG. The base payment rate is divided into a labor-related and nonlabor share.

What is a working DRG?

Working DRGs are defined as DRGs allocated on admission based on the presenting problem or provisional diagnosis. Patients were then concurrently reviewed until discharge. Actual length of stay (LOS) of patients was compared to the LOS predicted by the working DRG.