Healthcare Payment Systems
Jennifer Doley, Mary J. Marian in Adult Malnutrition, 2023
The principal diagnosis necessitating hospital admission decides the Major Diagnostic Category (MDC) assigned to the patient for that hospital stay.3 Within this MDC, the individual Diagnosis Related Group (DRG) is determined based on details of the patient’s diagnosis and hospital treatment. If the patient is managed medically, the principal diagnosis determines the DRG assignment; if the patient is primarily managed surgically, then the type of surgery will determine the DRG assignment. Secondary diagnoses, known as Complications or Comorbidities (CCs) and Major Complications or Comorbidities (MCCs), can increase the cost of care above what would have been required if the patient only needed treatment for the principal diagnosis. When these secondary diagnoses are documented, treated, and coded, the patient may be assigned to a different severity level within the DRG grouping; this is then known as the Medicare Severity – DRG (MS-DRG). See Figure 14.1. A higher payment is given to hospitals for MS-DRGs associated with a CC, and an even higher payment for MS-DRGs associated an MCC.3
Life Care Planning Resources
Roger O. Weed, Debra E. Berens in Life Care Planning and Case Management Handbook, 2018
There are states that provide inpatient facility information per MS-DRG (Medicare Severity Diagnosis Related Group) and some APR-DRG (All Patient Refined Diagnosis Related Group, developed by 3M). One of the state databases is PricePoint. The states of Washington, Utah, Virginia, Wisconsin, Nevada, and Texas all utilize PricePoint. Other sources include the state's hospital association. Make sure when utilizing these databases that the information is presented as charges and not costs. A simple way to access the database is to perform a Google search for hospital charges for the state in which the cost research is being done and the information, if available for the particular state, may be available. For example, California provides data under the Office of Statewide Health Planning and Development (OSHPD), http://www.oshpd.ca.gov/chargemaster/Default.aspx. Be careful if using one of the hospital Chargemasters because a hospitalization will require more than just one item, usually multiple items. This applies to outpatient procedures as well.
Medicare Set-Asides
Julie Dickinson, Anne Meyer, Karen J. Huff, Deborah A. Wipf, Elizabeth K. Zorn, Kathy G. Ferrell, Lisa Mancuso, Marjorie Berg Pugatch, Joanne Walker, Karen Wilkinson in Legal Nurse Consulting Principles and Practices, 2019
Surgery pricing includes physician, facility, and anesthesia fees and each must be determined separately and added together. For physician fees, Current Procedural Terminology (CPT) codes are used to identify fee schedule pricing, unless claimant resides in an actual charges state and usual and customary pricing used. Anesthesia fees are also calculated per fee schedule based upon a reasonable time for the procedure in question. Facility fees however require use of diagnosis-related group (DRG) codes to estimate inpatient procedures. CMS uses the pricing for a major medical center in that state, regardless of where claimant lives, unless the state fee schedule provides pricing for that DRG. If an outpatient procedure, the Ambulatory Payment Classification calculator is used for a facility in that state, again unless fee schedule provides a cap. More specific surgery calculation instructions and CPT codes can be found in Section 9.4.5 of the WCMSA Reference Guide (CMS, 2018a).
Exploring clinical metrics to assess the health impact of traffic injuries
Published in International Journal of Injury Control and Safety Promotion, 2018
Sara Ferreira, Marco Amorim, António Couto
In fact, besides ICD, which is used to describe the patient diagnostic, other medical code named diagnosis-related group (DRG) is commonly used in hospitals all over the world as the principal mean of reimbursing hospitals for acute inpatient care. However, in contrast to the ICD for which was developed systematic process to obtain an injury scale for traffic safety analysis, no process was established to a systematic use of DRG to analyse traffic injuries impact. Nevertheless, the DRG and ICD as clinical metrics have the main potential to allow a benchmarking analysis among countries and/or regions because they are supported by international standard codes. The long history and experience on using these metrics ensure the necessary stability of the estimated process to support a robust impact analysis across countries and regions. As such, the present study explored the use of clinical metrics, ICD and DRG as well as the length of hospital stay (LHS), reported by hospitals to assess the impact of traffic injuries. Using these metrics, health care costs, MAIS and injury description (e.g. body region) were obtained. Then, a statistical analysis of these metrics was conducted in order to assess the impact of traffic injuries on victims (type of injury and severity) as well as on medical care (health care costs and length of hospital stay). The objectives were (1) to explore the associations between these various metrics and the consequences of crashes mainly through the costs and severity, and (2) to develop a robust model to easily and routinely estimate the impact of injuries supported by DRG and ICD data.
Cluster analysis identifies unmet healthcare needs among patients with rheumatoid arthritis
Published in Scandinavian Journal of Rheumatology, 2022
N Mars, AM Kerola, MJ Kauppi, M Pirinen, O Elonheimo, T Sokka-Isler
The healthcare utilization data involved a system similar to diagnosis-related group (DRG), one suitable for both inpatient and outpatient care. This was used for grouping all the RA patients’ diagnoses for fiscal year 2014, and for estimating the respective health service-related direct costs (€; price level for 2014). The cost estimation tool acknowledges disease category, age, gender, healthcare unit and provider, and procedures, and comprises all public healthcare contacts: both primary and speciality care, inpatient and outpatient care, the emergency department, and contacts with all healthcare professionals (physicians, nurses, and rehabilitation workers). Additional details of both data sets have been described previously (10). We combined the data sets using the unique Finnish national identification numbers, selecting RA patients with at least one healthcare contact in 2014. As healthcare utilization data were obtained for 2014, our inclusion criteria were patients diagnosed with RA before or in 2014, who had visits to the rheumatology clinic within 5 years prior (2010–2014) to collection of cost data. To capture patterns of persistent disease activity, pain, and physical disability, we used all individual-level clinical data available for these patients within the registry (2007–2016).
Economic and clinical benefits of early identification of acute kidney injury using a urinary biomarker
Published in Journal of Medical Economics, 2019
Mauricio A. Berdugo, Noam Y. Kirson, Louise Zimmer, Hadi Beyhaghi, Seth Toback, Lauren M. Scarpati, Michael N. Stone, Ross Dember, Joshua Tseng-Tham, Jody Wen, Mark Miller
The hospital perspective used in the model assumed a diagnosis-related group (DRG) based capitated reimbursement for Medicare- and Medicaid-insured patients, and counted all reductions in length of stay as savings to the hospital in terms of uncompensated care for such patients. However, it is possible that differential rates of complications due to improved diagnostic efficacy could affect a patient’s DRG classification, and therefore the capitated rates used. Due to the complex array of factors that determine the precise reimbursement rates for specific DRGs at the individual hospital level, our model did not attempt to capture such changes. Future research should consider estimating the likelihood of differential DRG classification due to the use of [TIMP-2]·[IGFBP7], as well as the potential differences in reimbursement rates.
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