1 reading: drgs (3rd revision) dikutip oleh dr. mayang anggraini naga mik-2009

1

Reading:

DRGs (3rd Revision)

Dikutip oleh

dr. Mayang Anggraini Naga

MIK-2009

2

DRGs (3rd Revision)

PP rate yang berdasarkan DRGs ditentukan di USA sebagai dasar hitungan Penagihan kembali biaya asuhan peserta asuransi kesehatan pemerintah Mecicare.

DRGs adalah bagan klasifikasi pasien-pasien yang diobati di rumah sakit berkaitan dengan jumlah biaya yang telah dikeluarkan rumah sakit bagi pasien terkait.

DRGs dikembangkan di Yale University dengan tujuan sebagai bagan efektif pemonitoran kualitas asuhan dan utilisasi pelayanan di suatu tetanan rumah sakit.

3

USA

Pada akhir th. 70-an DRGs dimanfaatkan sebagai dasar PPS, rumah sakit dibayar kembali dengan jumlah yang

telah dipastikan sesuai DRG setiap pasien.

1982: The Tax Equity and Fiscal Responsibility Act modified Section 223 Medicare hospital reimbursement limits to include a case mix adjustment based on DRGs.

1983: Congress amended the Social Security Act to include a national DRG-based hospital prospective payment system for all Medicare patients.

4

USA (Cont.-1)

DRGs as the basic unit of payment in Medicare’s hospital reimbursement system represents a recognition of the fundamental role which a hospital’s case mix plays in determining its costs.

In the past, hospital characteristics such as teaching status and bed size have been used to attemp to explain the substantial cost differentces which exist across hospitals.

However, such charateristic failed to account adequately for the cost impact of a hospital’s case mix.

5

USA (Cont.-2)

• Individual hospitals have often attempeted to justify higher cost by contending that they treated a more “complex” mix of patients; the usual contention being that the patients treated were “sicker.”

• Although there has been a consencus in the hospital industry that a more complex case mix results in higher costs, the concept of case mix complexity had historically lacked a precise definition.

• The development of the DRGs provided the first operational means of defining and measuring a hospital’s case mix complexity.

6

The concept of Case Mix Complexity

• The concept of case mix complexity initially

appears very straight forward.

However,

- clinicians,

- administrators and

- regulators

have often attached different meanings to the concepts of case mix complexity depending on their backgrounds and purposes.

7

The concept of Case Mix Complexity (Cont.-1)

• The term case mix complexity has been used to refer to an interrelated but distinct set of patient atributes which include:

- severity of illness, - prognosis, - treatment difficulties, - need for intervention and - resource intensity.

Each of theses concepts has very precise meaning which describes a particular aspect of hospital’s case mix.

8


• Severity of illness

refers to the relative levels of loss of function and mortality that may be experienced by patients with a particular disease.

• Prognosis

Refers to the probable outcome of an illness including the likelihood of improvement or deterioration in the severity of the illness, the likelihood for recurrence and the probable life span.

9


• Treatment Difficulty:

refers to the patient management problems which a particular illness presents to the

health care provider. Such management

problems are associated with illnesses

without a clear pattern of symptoms, illness

requiring sophisticated and techincal difficult

procedures and illness requiring close

monitoring and supervision.

10


• Need for Intervention:

relates to the consequrnces in terms of severity of illness that lack of immediate orcontinuing care would produce.

• Resource Intensity:

refers to the relative volume and types of diagnostic, therapeutic and bed services used in the managment of a particular

illness.

11


• When the clinicians use he notion of case mix complexity, they mean that the patient treated have:

- greater sverity of illness,

- present greater treatment difficulty,

- have poorer prognoses, and

- have greater need for interventions.

Thus, from a clinical perspective case mix complexity refers to the condition of the patients treated and the treatment difficulty associated with providng care.

12


• On the other hand, administrators and regulatorsusually use the concept of case mix complexity to indicate that the patients treated require more resources which results in a higher cost of providing care.Thus, from an administrative or regulatoryperspective case mix complexity refers to the resource intensity demands that patients place on an institution. While tontwo interpretations of case mix complexity are often closely related, the can be very different for certain kinds of patients.

13

For example,

while terminal cancer patients are very severely ill and have a poor prognosis, they require few hospital resource

beyonds basic nursing care.

In the past, there has sometimes been confusion regarding the use and interpretation of the

DRGs because the aspect of case mix complexity measured by the DRGs has not been clearly understood.

14


• The purpose of the DRGs is to relate a hospital’s case mix to the resource demands and associated costs experienced by the hospital.

Therefore, a hospital having a more complex case mix from a DRGs perspective means that the hospital treats patients who require more hospital resources but not neccessarily that the hospital treats patients having a greater severity of illness, a greater treatment difficulty, a poorer prognosis or a greater need for intervention.

15

Patient Classification

• Given that the purpose of the DRGs is to relate a hospital’s case mix to it resource intensity, it was necessary to develop an operational means of determining the types of patients treated and relating each patient type to the resources they consumed.

While all patients are unique, groups of patients have demographic, diagnostic and therapeutic attributes in common that determine their level of resource intensity.

16

Patient Classification (Cont.-1)

By developing clinically similar groups of patients with similar resource intensity, patients can be aggregated into meaningful patient classes.

Moreover, if these patient classes covered the entire range of patient seen in an inpatient setting, then collectively they would constitute a patient classification scheme that would provide a means of establishing and measuring hospital case mix complexity.

17


The DRGs were therefore developed as a patient classification scheme consisting of classes of patients who were similar clinically and in terms of their consumption of hospital resource.

In order to understand the methods developed to contruct the DRGs, it is important to understand the two types of patient classification in use prior to the developement of the DRGs.

18


1. to define a patient class solely based on principal diagnosis.Principal diagnosis is the diagnosis established after study to be chiefly responsible for causing the patient’sadmission to the hospital.

However, principal diagnosis was found not to be sufficinet for classifying patients wit respect to resource intensity since other variables such as the surgical procedures performed and the age of the patient are important determinants of resource intensity.

19

Contoh (For Example):

• Pasien dengan diagnosis utama terkait gastric ulcer (tukak lambung) dan peptic ulcers (tukak peptik) tanpa tindakan operasi atau diagnoses komplikasi akan khusus dirawat selama 6 hari, sedangkan pasien dengan tindakan operasi mayor umpamanya Gastric resection disertai diagnoses komplikasi bisa perlu rawat sampai 15 hari.

Contoh sederhana ini: bila LOS digunakan sebagai alat pengukur intensitas sumber akan menghasilkan informasi tambahan ke diagnosis utama, yang perlu diperhatikan untuk dimasukan ke skema klasifikasi pasien.

20


2. The second method for classifying patients was developed by the Commssion on

Profesional and Hospital Activities (CPH

CPAH classification divided all possible principal diagnoses into 439 mutually exclusive major diagnostic categories. Each of these major diagnostic categories was the divided based on the presence or absence of a sedondary diagnosis, presence or absence of any surgery and five age categories. These resulted in 20 subcategories for each of the 349 major diagnostic categories for total of nearly 7000 patient classes.

21


The large number of classes presented operational problems since for a typical hospital most of the classes were empty or had just a few patients.

Further, because of its uniform structure throughout all 349 diagnostic categories, the CPHA classification tended to overspecify in some diagnostic categories (e.g., age is not particularly relevant with respect to resource intensity for senile cataract patients) and under-specify in other areas (e.g., the precise type of surgery is important for ulcer patients).

22


Thus, at the time the development of DRGswas initiated, neither of the existing patient classification schemes were able to adequately define hospital case mix and its relationaship to resource intensity.

• Since existing classification schemes were not satisfactory, it was necessary to develop the DRGs as a new patient calssification scheme.

23


During the process of developing the DRGs

patient classification scheme, several alternative

approaches to constructing the patient classes

were investigated.

Initially, a normative approach was used which

involved having clinicians define the DRGs using

the patient charateristics which they felt were

important for determining resource intensity.

24


There was a tendency for their definitions to include an extensive set of specifications, requiring information which might not always be collected through a hospital’s medical information system.

If the entire range of patients were classified in this manner, it would ultimately lead to thousands of DRGs, most of which described patients seen infrequently in a typical hospital.

25


It, therefore, became evident that the process of DRG definition would be facilitated if data

from acute care hospital could be examined to determine the general characteristics and relative frequency of different patient types.

In addition, statistical algorithms applied to thisdata would be useful to suggest ways of forming

DRGs that were similar in terms of resource intensity.

26


However, it was also discovered that stratistical algorithms applied to historical data in the absence of clinical input would not yield a satisfactory set of DRGs.

The DRGs resulting from such a statistical approach, while similar in terms of resource intensity, would often contain patient with a diverse set of characteristics which could not be interpreted from a clinical perspective.

27


Thus, it became apparent that the development of the DRG patient classification scheme required that:- physician judgement, - statistical analysis and - verification with historical data be merged into a single process.

28


It was necessary to be able to examine large

amounts of historical data with statistical to be

able to examine large amounts of historical data

with statistical algorithms available for

suggesting alternative wys of forming DRGs but

to do so in such a way that physicians could

review the results at each step to insure that the

DRGs formed were clinically coherent.

29

Basic Characteristic of the DRG Patient Classification Scheme

• Given the limitation of previous patient classification schemes and the experience of attempting to develop DRGs with physician panels and statistical analysis, it was concluded that in order for the DRG patient classification scheme to be practical and meaningful it should have the following characteristic:

30

Basic Characteristic of the DRG Patient Classification Scheme(Cont.-2)

• 1. The patient characteristic used in the definition of the DRGs should be limited to information routinely collected on hospital abstract systems.

• 2. There should be a manageable number of DRGs which encompass all patients seen on an inpatient basis

• 3. Each DRG should contain patients with similar pattern of resource intensity

• 4. Each DRG should contain patients who are similar from a clinical perspective (i.e. each class should be clincally coherent)

31


• Restricting the patient characteristics used inthe definition of the DRGs to those readily available insured that the DRGs could be extensively applied.Currently, the patient information routinely collected includes:

- age, - principle diagnosis, - secondary diagnoses and - the surgical procedures performed.

32


Creating DRGs based on information that is only collected in a few settings or on information which is difficult to collect or measure would have resulted in a patient classification scheme which could not be applied uniformly across hospitals. That is not to say that information beyond that currently collected might not be useful for defining the DRGs.As additional information becomes routinely available it must be evacluated to determine if it might result in improvements in the ability on classify patients.

33


Limiting the number of DRGs to manageable number (i.e. hundreds of patient classes, not thousands) insures that the most of the DRGs, a typical hospital will have enough experience to allow meaningful comparative analysis to be performed.

If there were only a few patients in each DRG, it would be difficult to detect patterns in case mix complexity and cost performance and to communicate the results to the physician staff.

34


• The resource intensity of the patients in each DRG must be similar in order to establish a ralationship between the case mix of a hospital and the resource it consumes.

Silimar resource intensity means that the

resource used are relatively consistent

across the patients in each DRG.

35


However, some variation in resource intensity will remain among the patients in each DRG. In other words, the definition of each DRG will not be so specific that every patient is identical, but the level of variation is known and predictable

Thus, while the precise resource intensity of a particular patient cannot be predicted by knowing to which DRG he belongs, the average pattern of resource intensity of a group of patients in a DRG can be accurately predicted.

36

The major application of the DRGs is as a means of communicating with thew physician community!

• The patients in each DRG musr be similar from a clinical perspective.

In other words, the definition of each DRG must be clincally coherent.

The concept of clinically coherence requires that the patient charateristics included in the definition of each DRG relate to a common organ system or etiology and that a specific medical specialty should typically provide care to the patients in the DRG.

37

For example:

Patients who are admitted for a D&C or Tonsillectomy are similar in terms of most measures of resource intensaity such as length of stay, preoperative stay, operating room time and use of anciullary services.

However, different organ systems and different medical specialties are involved.

Thus, the requirement that the DRGs be clinically coherent preclude the possibility of these types of patients being in the same DRG.

38

The major application of the DRGs is as a ... (Cont.-1)

• A common organ system or etiology and a common clinical specislity is a necessary but not sufficient requirement for a DRG to be clinically coherent. In addition, all available patient characteristics which medically would be expected to consistenly affect resource intensity should be included in the definition of the DRG.

Furthermore, a DRG should not be based on patient charateristics which medically would not be epected to consistently affect resource intensity.

39

For Example

• Patient with appendicitis may or may not have peritonitis. Although these patients are the same from an organ system, etiology and medical specialist perspective, the DRG definition must form separate patient classes, since the presence of peritonitis would be expected to consistenly increase the resource intensity of the appendicitis patients. On the other hand, sets of unrelated surgical procedures cannot ber used to define a DRG since there would not be a medical rationale to substantiate that the resource intensity would be expected to be similar.

40


• The definition of clinical coherence is of course,

dependent on the purpose for teh formation of

the DRG classification.

For DRGs, the definition of clinical coherence

relate to the medical rationale for differences in

resource intensity.

41


If, on the other hand, the purpose of the DRGs

related to mortality, the patient characteristics

which were clinically coherent and, therefore,

included in the DRG definitions might be

different.

• Finally, it should be noted that the requirement that the DRGs be clinically coherent caused more patient classes to be formed than would be necessary for explaining resource intensity alone.

42

Formation of the DRGs

• The process of forming the DRGs was begun by dividing all pasible principal diagnoses into 23 mutually exclusive principal diagnosis areas referred to as Major Diagnostic Categories (MDCs).

The MDCs were formed by physician panels as the first step toward insuring that the DRGs would be clinically coherent. The Diagnoses in each MDCs correspond to a single organ system or etiology and in general are associated with a particular medical speciality.

43

Formation of the DRGs (cont.-1)

Thus, in order to maintain the requirement of clnical coherence, no final DRG could contain patients in different MDCs.

• In general, each MDC was constructed to correspond to a major organ system (e.g., Respiratory System, Circulatory System, Digestive System) rahter than etiology (e.g. malignancies, Infectious diseases).This approach was used since clinical care is generally organized in accordance with the organ system affected, and not the etiology.

44


Thus, diseases involving both a particular organ system and particular etiology (e.g., malignant neoplasm of the kidney) were assigned to the MDC corresponding to organ system involved.

However, not all diseases or disorders could be assigned to an organ system-based MDC and a number of residual MDCs were created (e.g., Systemtic Infectious Diseases, Myeloprolifera-tive Diseases and Poorly Differentiated Neoplasms).

45

For Example:

• The infectious diseases, food poisoning, and Shigella dysentriae are assigned to the Digestive System MDC while pulmonary tuberculosis is assigned to the Respiratory System MDC.

On the other hand, infectious diseases such as miliary TB and septicaemia which usually involve the entire body are assigned to the Systemic Infectiuos Disease MDC.

46

The medical-surgical distinctionis also useful in further defining

the clinical specialty involved

• Once the MDCs were defined eachMDC was evaluated to identify those additional patient characteristics which would have a consistent effect on the consumption of hospital resources.

Since the present of a surgical procedure which required the use of the operating room would have a significant effect on the type of hospital resources (e.g., operating room, recovary room, anesthesia) used by a patient, most MDCs were initially divided into medical and surgical groups.

.

47

The medical-surgical distinction (Cont.-1)

• Patient were considered surgical if they had a procedure performed which would require the use of the operating room.

Since the patient data generally available does not precisely indicate whether a patient was taken to the operating room, surgical patients were identified based on the procedures which were performed.

Physician panels classified every possible procedure code based on whether the procedure would in most hospitals be performed in the operating room.

48

The medical-surgical distinction (Cont.-2)

• Thus, closed heart valvotomies, cerebral meninges biopsies and total cholecystectomies would be expected to require the operating room while thoracentesis, bronchoscopy and skin sutures would not.

If a patient had any procedure performed which was expected to require the operating room that patient would be classified as a surgical patent.

(Read: Appendix A)

49


• Once each MDC was divided into medical and surgical categories, then, in general, the surgical patients were further defined based on the precise surgical procedure performed while the medical patients were further defined based on the precise principal diagnosis for which they were admitted to the hospital.

In general, specific groups of surgical procedures were defined to distinguished surgical patients according to the extent of the surgical procedure performed.

50

For Example:

• The procedure classes defined for the Endocrine, Nutritional and Metabolic MDC are: - amputations, - adrenal and pituitary procedures, - skin grafts and wound debridements, - procedures for obesity, - parathyroid procedures, - thyroid procedures, - thyroglossal procedures and - other procedures relating to Endocrine,

Nutritional or Metabolic diseases

51


• Since a patient can have multiple procedures related to their principal diagnosis during a particular hospital stay, and a patient can be assigned to only one surgical class, the surgical classes in each MDC were defined in a hierarchial order.

Patients with multiple procedures would be assigned to the surgical class highest in the hierarchy.

52


• Thus if a patient recieved both a D&C and a hysterectomy, the patient would be assigned to the hysterectomy surgical class.

It should be noted that as a result of the surgical hierarchy the ordering of the surgical procedures on the patient abstract has no influence on the assignment of the surgical class and DRG.

(See Appendix B)

53


• In general, specific groups of principal diagnoses were defined for medical patient.

Usually the medical classes in each MDC would include a class for:

- neoplasms,

- symptoms and

- specific conditions relating to the organ

system involved.

54

For Example:

• The medical classes for the Respiratory System MDC are:

- pulmonary embolism,

- infections, - neoplasms,

- chest trauma, - pleural effusion,

- pulmonary edema - respiratory failure,

- chronic obstructive pulmonary disease,

- simple pneumonia,

- interstitial lung disease,

- pneumothorax, - bronchitis and asthma,

- respiratory symptoms and

- other respiratory diagnoses.

55


In each MDC there is usually a medical and a surgical class referred to as “other medical diseases” and “other surgical procedures”, respectively.

The “other” medical and surgical classes are not as precisely defined from a clinical perspective.

The other classes would include diagnoses or procedures which were infrequently encountered or not well defined clinically.

56

For Example:

• The “other” medical class for the Respiratory System MDC would contain the diagnoses:

- “psychogenic respiratory disease” and

- “respiratory anomalies not otherwise specifed”,

while the “other” surgical class for the female reproductive MDC would contain the surgical procedures “liver biopsy” and “exploratory laparotomy”.

57


• The “other” surgical category contains surgical procedues which, while infrequent, could still reasonably be expected to be performed for a pateint in the parrticular MDC.

There are, however, also patients who recieve surgical procedures which are completely unrelated to the MDC to which the patient was assigned.

58

For Example:

• A patient with a principal diagnosis of pneumonia whose only surgical procedure is a transurehral prostatectomy.

Such patients are assigned to a surgical class referred to as “unrelated operating room procedures”.

Theses patients are ultimately never assigned to a well defined DRG.

59


• The process of defining the surgical and medical classes in an MDC required that each surgical or medical class be based on some organizing principle.Examples of organizing principles would be:

- anatomy, - surgical approach, - diagnostic approach, - pathology, - etiology or - treatment process.

60


• In order for a diagnosis or surgical procedure to be assigned to a particular class, it would be required to correspond to the particular organizing principle for that class.Example:In the Urinary System MDC a surgical group was formed for all pasients with a procedure on the urethra (i.g., organizing principle based on anatomy). This surgical group was then further divided based on whether the procedure performed was transurehral (e,g., organizing principle based on surgical approach)

61


• Once the medical and surgical classes for an MDC were formed, each class of patients was evaluated to determine if complications, comorbidities or the patient’s age would be consistently affect the consumption of hospital resources.

Physician panel classified each diagnosis code based on whether the diagnosis, when present as a secondary condition, would be considered a substantial complication or comorbidity.

62


A substantial complication or comorbidity was defined as a condition, that because of its presence with a specific principal diagnosis, would cause an increase in LOS by at least one day in at least 75% of the patients.

For example:

Sarcoidosis, chronic airways obstruction and pneumococcal pneumonia are considered substantial complications or comorbidies, while simple goiter and benign hypertension are not.

63


• Each medical and surgical class within an MDC was tested to determine if the presence of any substansial comorbidities or complications would consistently affect the consumption of hospital resource.

For example:

The presence of complications or comorbidities was not significant for patients receiving a carpal tunnel release but was very significant for patients with arrhytmia and conduction disorders.

64


In general, the same list of complications and comorbidities was used across all MDCs.

However, in some cases such as Newborns or Acute Myocardial Infarction patients, special complications and comorbidity definitions were used in defining the DRGs.

(A complete list of the diagnoses generally considered a complication, or comorbidity is contained in Appendix C)

65


• The patient’s age was frequently used in the definition of the DRGs. Pediatric patients (age 17 years or less) and elderly patients (age 70 years or more) were often assigned to separate DRGs.

For example:

Pediatric asthma patients were defined as a specific DRG.

The presence of a complication or comorbidity and age 70 or over were found to be highly interrelated.

66


Age 70 and over or the presence of a significant complication or comorbidity were found to have a similar impact on hospital resources.Therefore, separate DRGs were often defined for patients who were either 70 or over or had a significant complication or comorbidity.Examples of medical or surgical classes of patients in which age over 70 or the presence of complications or comormidities was found to be significant are: - atherosclerosis,

- pleural effusion and - rectal resections.

67


• The final variable used in the definition of the DRGs was the patient discharge status.

Separate DRGs were formed for burn patients and newborns if the patients were transferred to another acute care fasility.

In addition, separate DRGs were found for patients with:

- alcoholism or drug abuse who left against medical advice and

- for acute myocardial infarction patients and

- newborns who died.

68


• The actual process of forming the DRGs was highly reiterative, involcing a combination of statistical results from test data with clinical judgment.At any point during the definition of the DRGs there would often be several patient chracteristics which appeare important for understanding the impact on hospital resources.The selection on the patient characteristics to be used and other order in which they would be used was a complex task with many factors examined and weighed simultaneously.

69


• The end result of the third revision of the DRGs was the creation of 469 patient classes or DRGs which encompass all patients treated in an inpatient setting.

In the third revision the DRGs are numbered 1-437, 439-467 and 472-473.

DRG number 438 is not used in the second or third revision.

A complete list of the DRGs in the third revision is contained in Appendix D.

70


• Since all patients cannot be assigned to a DRG, there are three additional patient classes referred to a classes 468, 469 and 470.If a patient’s medical record abstract contains invalid information or if the clinical information on abstract contain certain types of inconsistences the patient may not be assigned to one of the 469 DRGs.These three additional patient classes have been defined to identify the situations in which a patient will not be assigned to one of the 469 DRGs.

71


• Patients are assigned to patient class 468 when all the operating room procedures performed are unrelated to te major diagnostic category of the patient’s principal diagnosis.

Thus a patient with a principal diagnosis of congestive heaert failure whose only procedure is acholescystectomy will be assigned to patient class 468 since the cholecystectomy is unrelated to Diseases of the Circulatory System.

72


Patient abstracts assigned to patient class 468 are often the result of medical record coding errors such as the coding of the wrong principal diagnosis.

However, patients with completely accurate medical records informtaion can also be assigned to patient class 468. Typically, these are patients who are admitted for particular diagnosid, develop a complication unrelated to the principal diagnosis and have an operating room procedure performed for the complication.

73

For Example:

• A patient admitted for pneumonia who has benign prostate hypertrophy and becomes obstructed and recieves a transurethral prostatectomy for the benign prostatic hypertrophy would be assigned to patient class 468. Thus the patient is in class 468 not because of a medical records error but because a pnemonia patient who recieved a TUR prostatectomy is clearly atypical both clinically and from a resource perspective and cannot be appropriatly associated with a DRG.

74


• Patients are assigned to patient class 469 when a principal diagnosis is coded which, although it is a valid ICD-9-CM code, is not precise enough to allow the patient to be assigned to a DRG.

For example:

ICD-9-CM code 64690 is an unspecified complication of pregnancy with the episode of care unspecified.

Thus, this diagnosis code does not indicate the type of complication nor whether the episode of care was antepartum, postpartum or for delivery.

75


• Since the DRG definitions assign patients to different sets of DRGs depending on whether the episode of care was:

- antepartum,

- postpartum or for

- delivery,

a patient with a principal diagnosis of 64690 cannot be assigned to a DRG and will be to patient class 46.

76


• It should be noted that patients with a principal diagnosis which is not typically considered a reason to be hospitalized are not assigned to patient class 469.

For example:

ICD-9-CM code V503, ear piercing, is assigned to DRG 467 and not patient class 469.

77


• Patient are assigned to patient class 470 if certain types of medical records errors which may affect DRG assignment are present.

Patient with a invalid or non-existent ICD-9-CM code as principal diagnosis willbe assigned to patient class 470.

Patiens will also be assigned to patient class 470 if their age, sex, or discharge status is both invalid and necessary for DRG assignment.

78

For Example:

If a patient has a nonnumeric age or has an age coded greater than 124 (age > 124 is considered invalid) and has a principal diagnosis atherosclerosis, the DRG assigment will be to patient class 470 since patients with atherosclerosis will be assigned to different DRGs depending on their age.On the other hand, if the same patient had a principal diagnosis of hypertension, the dRG assigment will not be to patient class 470, since age is not used in the determination of the DRG for hypertensive patients.

79

SUMMARY

• The DRGs, as they are now defined, form a manageable, clinically coherent set of patient classes that relate a hospital’s case mix to the resource demands and associated costs experienced by the hospital.DRGs are defined based on the:- principal diagnosis,- secondary diagnoses, - surgical procedures,- age, sex and - discharge status of the patient treated

80

Summary (Cont.-)

• Through DRGs, hospital can gain an understanding of the patients being treated, the costs incurred and within reasonable limits, the services expected to be required.The classification of patients into DRGs is a constantly evolving process.As coding scheme change, as more comprehensive data is collected or as medical technology or practice changes, the DRG definition will be reviewed and revised.

81

MAJOR DIAGNOSTIC CATAGORIES (23 MDC)

1 – Diseases & Disorders of the Nervous System

2 – Diseases & Disorders of the Eye

3 – Diseases & Disorders of the Ear, Nose & Throat

4 – Diseases & Disorders of the Respiratory System

5 – Diseases & Disorders of the Circulatory System

6 – Diseases & Disorders of the Digestive System

7 – Diseases & Disorders of the Hepatocellular System

and Pancreas

8 – Diseases & Disorders of the Musculoskeletal System

and Connective Tissue

82

(MDC) (Cont.-1)

9 – Diseases & Disorders of the Skin, Subculaneous Tissue and Breast

10 – Endocrine, Nutritional and Metabolic Diseases & Disorders

11 – Diseases & Disorders of the Kidney and Urinary Tract

12 – Diseases & Disorders of the Male Reproductive System

13 – Diseases & Disorders of the Female Reproductive System

14 – Pregnancy, Childbirth and the Puerperium

15 – Newborns and Other Neonates with Conditions Originating in the Perinatal Period

83

(MDC) (Cont.-2)

16– Diseases & Disorders of Blood and Blood Forming Organs Immunological Disorders

17 – Myeloproliferative Diseases & Disorders, and Poorly

Differentiated Neoplasms

18 – Infectious & Parasitic Diseases

19 – Mental Diseases & Disorders

20 – Alcohol/Drug Use & Alcohol/Drug Induced Organic Mental Disorders

21 – Injuries, Poisonings and Toxic Effects of Drugs

22 – Burns

23 – Factors Influencing Health Status and Other Contacts with Health Services

84

The Description of the Patient Attributes which define each DRG begins with a one line Description of the

DRG.

• This description includes the DRG number, the MDC number, a letter indicating whether the DRG is medical (M) or Surgical (P) and a brief description of the DRG.

Following the DRG description is a series of headings which indicate the patient characteristic used to define the DRG.

These headings indicate how the patient’s diagnoses and procedures are used in determining DRG assigment.

85

The Description of the ... (Cont.-1)

Following each heading is a complete list of all the ICD-9-CM diagnosis or procedure codes which are included in the DRG. It should be noted that there are no headings corresponding to age, the presence or absence of a complication or comorbidity, or discharge status.

If these patient atributes are used in the DRG definitions they are specified in the initial description of the DRG. The DRGs are listed in hierarchical order.

86

The Following Headings Appear in the DRG Definition:

• Principal Diagnosis Indicates that a specific set of principal diagnoses are used

in the definition of the DRG

• Operating Room Indicates that a specific set of

Procedures: procedures are used in the definition of the DRG. The list of

procedures contains only pro-cedures which are expected

to require the operating room (see Appendix A)

87

• Non-Operating Room Indicates that a specific set of

Procedures procedures are used in the definition of the DRG. The set

of procedures contains only

procedures which are not expected to require the operating room (i.e.

procedures

not listed in Appendix A).

For example:

Cardiac catherization is used to defiine DRG 106.

88

• With or Without Non- Indicates that either a specific

Operating Room set of non-operating room

Procedures procedures or other specified criteri is used in the definition of the DRG.

For example:

In order to be assigned to DRG 323, a patient must have a

principal diagnosis of urinary stones with ESWL performed

or without ESWL performed.

Age >69 &/or CC

89

• Any Operating Room Indicates that the presence of

Procedure: any procedure which is expected to require the operating rom (see Appendix A) is used in the definition of thDRG.

For example:

Patients with systemic infectious diseases are assigned to DRG 415 if any operating room procedure is performed.

90

• Only Operating Room Indicates that in order to be Procedures: assigned to the specified DRG

no procedures other than the ones listed may appear on

thepatient’s record.For example:In order to be assigned to

DRG 59 a patient must not have any operating room procedures

performed other than a tonsillectomy or

adenoidectomy.If any other operating room procedures are

performed the patient is assigned to a different DRG.

91

• Operating Room Indicates that one of the

Procedures and CC specified operating rom pro-cedure and a complication or

co-morbidity (CC) are used in the definition of the DRG.

For example:

One way for a patient to be assigned to DRG 223 would

be to have a shoulder, elbow or forearm procedures and a

CC.

92

• Principal or Indicates that a specific set of

Secondary Diagnosis: diagnoses are used in the

definition of the DRG. The diagnoses may be listed as principal or as any one of thesecondary diagnoses.

A special case of this condition is DRG 121 in which two diagnoses (e.g., an acute

myocardial infarction and a cardiovascular complication) must both be present somewhere in the list of diagnoses in order

to be assigned to DRG 121

93

• Secondary Diagnosis Indicates that a specific set of secondary diagnoses are used in the definition of the DRG.

For example:

The presence of a secondary diagnosis of history of malignancy

is used to define DRG 465.

94

• Only Secondary Indicates that in order to be

Diagnoses: assigned to the specified DRGno secondary diagnoses other than those in the specified list may appear on the patient’s record.

For example:

In order to be assigned to DRG 391, only secondary diagnoses from the spesified lst may appear on the patient’s record.

95

Appendix G – ABBREVIATIONS

• Appendix G provides a definition of all abbreviations used in the tree diagrams and in the descriptiion of the DRGs.

For example:> 1 HR Greater than 1 hourACF Acute Care FacilityADENOIDECT AdenoidectomyADNEX Adnexal

etc.

1 reading: drgs (3rd revision) dikutip oleh dr. mayang anggraini naga mik-2009

Documents