When is drg assigned

Code assignment is dictated by the Rules and Guidelines established and updated annually by the Federal Government. Not adhering to these guidelines for documentation and coding constitutes fraud and is subject to prosecution. All Diagnosis that affect the current patient encounter must documented and coded. Diagnoses that relate to an earlier admission, but which have no bearing on the current admission are to be excluded from coding.

Signs, symptoms and observations should be documented as a diagnosis whenever possible to provide adequate substantiation of coding for severity of illness and risk of mortality. Significant Procedure : A significant procedure is one that carries an operative or anesthetic risk or requires highly trained personnel or special equipment.

All significant procedures are to be documented in the patient record. DRGs are determined by the principal procedure, or the principal diagnosis if no procedure exists, and the presence of other conditions.

DRGs group patients with similar resource consumption, severity of illness and length of stay into payment groups. DRGs are used for determining reimbursement and as an indicator for other types of reporting such as budgeting, physician profiling, clinical outcomes, case mix calculation and clinical research.

Coding is transforming the verbal description of disease, injuries and procedures into numerical codes. This payment plus the member copayment represents payment in full to the hospital. Note: Charges for non-covered services, such as personal care and convenience items, are the member's responsibility. These charges should be billed to the member along with the member's copayment.

Although the DRG grouper is updated on October 1 each year due, concurrent with changes to the ICD coding manual, the payment schedule is updated according to the facility's Participating Agreement. These exceptions are outlined in the facility's Participating Agreement. Non-discrimination notice. Diagnosis Related Group DRG A diagnosis-related group DRG is a patient classification system that standardizes prospective payment to hospitals and encourages cost containment initiatives.

Claims for the inpatient stay are submitted and processed for payment only upon discharge. The assignment of a DRG depends on the following variables: Principal diagnosis Secondary diagnosis es Surgical procedures performed Comorbidities and complications Patient's age and sex Discharge status Outliers DRG payment is based on the care given to and resources used by a "typical" patient within the group. Grouper A grouper is a software program designed to assign the DRG classification.

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Completely revised to include new titles for contract addenda, a paragraph about what is included in the DRG.