Jim,
This is not a local code issue at all. The New York State DRG is
derived from standard data in an 837, ICD-9-CM diagnosis and procedure
information, patient status, birthdate, birthweight, and something I know I
am forgetting. The only thing sent to the state from providers are the
standard data elements needed to derive the NYS DRG. One of the main
reasons we have a NYS DRG is that the Medicare Grouper does not provide
newborn DRGs. That is not an issue for Medicare, but is very much an issue
for NYS Medicaid.
I don't think there can ever be a standard grouper, because there are
lots of legitimate reasons why different organizations would want to group
the data in different ways. The only thing that needs to fit the standard
are the data elements needed to derive the wanted DRG, which from what I
understand is the case today.
Bob Davis
"Jim Whicker"
<[EMAIL PROTECTED] To: <[EMAIL PROTECTED]>
> cc:
Subject: RE: DRG question
04/26/2002 02:41
PM
Sounds like a "local code" to me... and therefore not allowed... Bob Davis
- thoughts?
>>> [EMAIL PROTECTED] 04/24/02 06:09AM >>>
st1\:*{behavior:url(#default#ieooui) }
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
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