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Getting the DRG back in the 835 is critical to doing reimbursement
analysis. You're right - there isn't a standard grouper - and I'd guess
you're right that the DRG table referenced in the imp guide was not named as a
"standard code set" - but I'd assume you'd have to treat it the same as any
other external code set - just like we will the UB92 code set?? I suppose
that if you were under contract with a payer to be reimbursed for
"specific" drg's that are not in the standard DRG list referenced in the IG,
then you'd have that built into your grouper...
>>> Jan Root <[EMAIL PROTECTED]> 04/29/02 01:09PM
>>>
Kepa
Actually, the DRG can be (and sometimes is) submitted
in the institutional claim. See the HI on page 230 in the May 2000
implementation guide.
It seems clear that there are two major components to the DRG issue.
(1)
there is the grouper - a piece of software that is (somewhat) payer
specific. The grouper is NOT listed in an external code source in the imp
guides. Groupers are used to come up with DRG numbers for specific claims.
(2) the DRG number. There appears to be only one source for DRG
numbers: HIM15 (Federal Register and Health Insurance Manual 15) which is listed
in Code Source 229.
Everyone who uses DRGs (in either the claim or the remittance advice) should
double check just to make sure that the DRG codes they are/will be sending are
actually listed in HIM15 (i.e., that they haven't created any DRGs on their
own). If they are not, then there is a question about whether they would
be HIPAA compliant if they used a DRG number that is not listed in HIM15.
The implementation guides appear to allow payers to use whatever grouper they
want as long as the codes that grouper references come from HIM15.
Jan Root
Kepa Zubeldia wrote:
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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