Jim,
Just to put some context around this, the DRG is not submitted in the claim,
it is a "notification" or "informational" sort of element returned in the 835
that tells the provider how the payer reached a certain payment decision.
And I agree with Bob, there are not only state specific DRGs but also a lot
of the commercial payers have made their own adjustments to their "groupers"
based on contractual requirements and other factors. I don't think the
Secretary adopted the DRGs as a standard code set or the Medicare grouper as
the standard grouper.
One solution is for the payer to not communicate the DRG in the 835 at all,
and essentially pay the claim without explaining why or how it was
calculated. Not the best solution...
Kepa
On Friday 26 April 2002 01:48 pm, Robert A. Davis wrote:
> 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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