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Diagnosis Related Groups (DRGs)

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Diagnosis Related Groups (DRGs). Diagnosis Related Group (DRG) : is a payment category that is used to classify patients, especially Medicare patients, for the purpose of reimbursing hospitals for each case in a given category with a fixed fee regardless of the actual costs incurred.

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Diagnosis Related Group (DRG):

is a payment category that is used to classify patients, especially Medicare patients, for the purpose of reimbursing hospitals for each case in a given category with a fixed fee regardless of the actual costs incurred.

  • DRG is based upon:
  • the principal ICD-9-CM diagnosis code
  • ICD-9-CM surgical procedure code
  • age of patient
  • expected length of stay in the hospital
  • In the mid 1970s the Centre for Health Studies at Yale University began work on a system for monitoring hospital utilization review. Following a 1976 trial of a DRG system, it was decided to base the final system on the ICD-9-CM which would provide the basic diagnostic categories
  • relate a patient’s diagnosis and treatment to the cost of their care
  • Developed in the United States by the Health Care Finance Administration
  • DRGs are used for reimbursement in the prospective payment system of US Medicare and Medicaid healthcare insurance systems
  • DRGs were designed to support the calculation of federal reimbursement for healthcare delivered through the U.S. Medicare system
drg structure
DRG Structure
  • Major Diagnostic category
  • Medical Surgical split
  • Complications & Comorbidities
  • Exclusion list
  • Structure diagram
  • DRG Example with severity score
major diagnostic category assignment mdc
Major Diagnostic Category Assignment (MDC)
  • The initial step in the determination of the DRG has always been the assignment to the appropriate MDC based on the Principal Diagnosis
  • Since the presence of a surgical procedure requires different hospital resources (operating room, recovery room, anesthesia) most MDCs were initially divided into medical and surgical groups
medical surgical split
Medical Surgical split
  • All procedure codes were classified based

on whether or not they required the use of

an operating room

  • Operating room procedures
  • – Cholecystectomies– Cerebral meninges biopsies– Closed heart valvotomies
  • Non operating room procedures
  • – Bronchoscopy– Skin sutures
complications comorbidities ccs
Complications & Comorbidities (CCs)
  • A complication is a condition which did not exist prior to the admission
  • A comorbidity is a condition which existed prior to admission
  • A complication or comorbidity is a secondary diagnosis which would be expected to extend the patient’s length of stay by at least one day in at least 75 percent of patients
major ccs
Major CCs
  • Within each MDC patients with major CCs (e.g., AMI, CVA, etc.) were assigned to separate DRGs
  • A major complication or comorbidity is a secondary diagnosis which would be expected to extend the patient’s length of stay by at least 3-4 days in at least 75 percent of patients
complication comorbidity cc exclusion list
Complication & Comorbidity(CC) Exclusion List
  • For a principal diagnosis of bladder neck obstruction

– Urinary retention is not a CC

  • For a principal diagnosis of general convulsive epilepsy

– Convulsion is not a CC

surgical hierarchy
Surgical Hierarchy
  • If multiple procedures are present, the patient is assigned to a single surgical DRG based on a surgical hierarchy within each MDC
drg assignment
DRG assignment
  • A DRG is assigned based on the patient\'s diagnosis (ICD-9-CM coding).  The encoder (also known as the DRG grouper) is a software program developed by CMS that places the patient into a Major Diagnostic Category based on the diagnosis.  
  • For example:  A patient with a fracture  would be grouped to the Musculoskeletal Major Diagnostic Category.  At this point, the patient is considered a medical DRG.  If the patient has a surgical procedure, then the patient is grouped to a surgical DRG.  The other factors that influence DRG assignment is age of the patient, any complication/comorbidities, and discharge status.  

DRGs will always only give approximate estimates of the true resource utilisation. For example, should a hospital that is developing new and expensive procedures be paid the same amount as an institution that treats the same type of patient with a more common and cheaper procedure? Should quality of care be reflected in a DRG? For example, if a hospital delivers good quality of care that results in better patient outcomes, should it be paid the same as a hospital that performs more poorly for the same type of patient?

As importantly, those institutions that are best able to create DRGs accurately are more likely to receive reimbursement in line with their true expenditure on care. There is thus an implication in the DRG model that an institution actually has the ability to accurately assemble information to derive DRGs . Given local and national variations in information systems and coding practice, it is likely that institutions with poor information systems will be disadvantaged.

  • DRGs are designed for use with inpatients. Accordingly, other systems have been developed for other areas of healthcare. Systems such as Ambulatory Visit Groups (AVGs) and Ambulatory Payment Classifications (APCs) have been developed for outpatient or ambulatory care in the primary sector. These are based upon a patient’s diagnosis, intervention, visit status and physician time.
drg audits
DRG audits

DRG audits may consists of evaluating those DRGs that are incorrectly used.  These audits may also focus on missing diagnoses, missing procedures, and incorrect principal diagnosis selection

For DRG based reviews, cases may be selected in a variety of ways:

  • • Simple random sample
  • • High dollar and high volume DRGs
  • • DRGs without comorbid conditions or complications
  • • Focused DRGs such as DRG 79 Pneumonia or DRG 416 Septicemia and other high
  • risk DRGs
  • • Correct designation of patient discharge and transfer status

در ايران اين نوع روش پرداخت بکار گرفته مي شود و نظام طبقه بندي اي که به عنوان پايه و اساس جهت بکارگيري روش پرداخت موردي استفاده مي شود نظامي با عنوان نظام" گلوبال" است. در اين نظام، بيماران بر طبق 60 مورد از اعمال جراحي شايعطبقه بندي مي گردند. نظام" گلوبال" در مقايسه با نظام "گروه هاي مرتبط تشخيصي" داراي نواقص بسياري است. نظام" گلوبال"، موارد بيماري را شامل نشده و تنها در مورد اعمال جراحي و تنها در 60 مورد کاربرد دارد. طبقات تشخيصي اصلي، گروه های مرتبط تشخيصی پايه که در نظام هاي "گروه هاي مرتبط تشخيصي" بطور جامع و کامل در نظر گرفته شده است در نظام " گلوبال" وجود ندارد. همچنين طبقاتي جهت اطلاعات غيرمعتبر و متناقض، و وضعيت ترخيص بيمار در نظر گرفته نشده است. متغيرهاي سن، جنس، وجود يا عدم وجود عوارض و بيماري هاي همراه، سطح خاص عوارض و بيماري هاي همراه، وزن زمان تولد/


پذيرش در نوزادان وجود نداشته و شدت بيماري و يا سطح پيچيدگي کلينيکي بيمار، ونيز خطرمرگ را نمي توان با توجه به اين نظام تعيين نمود . در نظام هاي "گروه هاي مرتبط تشخيصي" به هر"گروه"، کدي تعلق مي گيرد کهبا کدهاي طبقه بندي بين المللي بيماري ها مرتبط و هماهنگ است، اما در نظام " گلوبال" کدگذاري انجام نمي شود. از طرفي ديگر عامل وزن نسبي يا وزن هزينه اي، که در محاسبه هزينه بيمار با توجه به نظام "گروه های مرتبط تشخيصي" جهت هر گروه،به طور جداگانه تعيين مي شود در نظام " گلوبال" درنظر گرفته نشده است. بدين ترتيب مي توان اظهار داشت نظام " گلوبال" در مقايسه با نظام "گروه های مرتبط تشخيصي" داراي کمبود ها و نواقصي است .