RE: DRG question

[Jim Whicker]

Sounds like a "local code" to me... and therefore not allowed... Bob Davis - thoughts? >>> [EMAIL PROTECTED] 04/24/02 06:09AM >>> I believe you're correct in saying that the Medicare Grouper is the most widely used.  In New York, we use a state specific grouper as well for Medicaid and some other payers.  This grouper has an extended DRG code set (more DRG codes than the Medicare Grouper).  Does anyone have any input as to whether or not that could be called compliant?     Stephen C. Block Director, Information Services St. Joseph's Hospital Health Center 301 Prospect Ave. Syracuse, NY  13203 (315)-448-5613 (phone) (315)-448-5424 (fax) -----Original Message----- From: Jan Root [mailto:[EMAIL PROTECTED]] Sent: Tuesday, April 23, 2002 4:48 PM To: [EMAIL PROTECTED] Subject: DRG question   All A few weeks ago a question was raised about the DRG code source that is listed in the 837 institutional implementation guide (it's in another guide as well - ??).  Specifically, it lists code source 229: Diagnosis Related Group Number (DRG).  The source for this code is the Federal Register and Health Insurance Manual 15 (HIM 15). The question was: does everyone use this particular DRG code source?  I am not an expert on DRGs (a very complex topic), but I asked a couple of people that I knew who are and here is what they told me. Code Source 229 is THE standard for DRG numbers.  That is, code 123 (not a real example) = hip replacement surgery is set in the Federal Register and Health Insurance Manual 15.   Code 123 always equals 'hip replacement surgery' for everyone. Of course, that is not the end of the story.... read on. The grouper is the software that you feed all the treatment information (diagnoses, procedures performed, age, weight, mitigating circumstances, etc) and it generates the appropriate DRG number for you.  The grouper would not give code 123 to a brain surgery operation. What varies from payer to payer is the grouper, or more specifically, how the grouper is programmed to come up with a particular DRG.  Payer A will say "assign DRG code 123 when the diagnosis is x, y, or z, the procedure code(s) is a,b,c,d, and/or e, the patient has j,k, & l characteristics, etc., etc.  Payer B will say "assign DRG code 123 when the diagnosis is w, x, or y, the procedure code(s) is c, d, e, f,and or g, and the patient has j, l, m, and n characteristics, etc. etc.  Hip replacement surgery is hip replacement surgery, but the exact list of diagnoses, procedure codes, (and so forth) that go into the grouper to program it to assign code 123 may vary from payer to payer.  So, number is standard but the grouper is not. My sources tell me that Medicare's grouper is probably the most widely used in their experience, but some payers have come up with other groupers. So, the short answer to the original question is that Code Source 229 does not appear to pose a HIPAA problem.  Everyone I talked with uses the identical DRG numbers.  However, how one comes to that number can vary (somewhat). I hope this answers the original question.  Those of you who know DRGs a lot better than I do - let me know if I got anything wrong. Jan Root   ********************************************************************** To be removed from this list, send a message to: [EMAIL PROTECTED] Please note that it may take up to 72 hours to process your request. ====================================================== The WEDI SNIP listserv to which you are subscribed is not moderated. The discussions on this listserv therefore represent the views of the individual participants, and do not necessarily represent the views of the WEDI Board of Directors nor WEDI SNIP. If you wish to receive an official opinion, post your question to the WEDI SNIP Issues Database at http://snip.wedi.org/tracking/. Posting of advertisements or other commercial use of this listserv is specifically prohibited. ********************************************************************** To be removed from this list, send a message to: [EMAIL PROTECTED] Please note that it may take up to 72 hours to process your request. ===================================================== The WEDI SNIP listserv to which you are subscribed is not moderated. The discussions on this listserv therefore represent the views of the individual participants, and do not necessarily represent the views of the WEDI Board of Directors nor WEDI SNIP. If you wish to receive an official opinion, post your question to the WEDI SNIP Issues Database at http://snip.wedi.org/tracking/. Posting of advertisements or other commercial use of this listserv is specifically prohibited.