Medicare Severity-Diagnosis Related Group Analysis

In 1974, the federal government adopted the Uniform Hospital Discharge Data Set (UHDDS) as the standard to help improve the uniformity and comparability of hospital discharge data, the principal diagnosis, and other diagnoses for hospital procedures; including comparable data that could help to determine which hospitals were best at treating patients and for reporting inpatient data in acute care, short-term care, and long-term care hospitals. This dataset works towards a standardized system of reimbursement for the federal government nationwide which in turn could lower costs, UHDDS helps in collecting general information pertaining the patient and the specific care including the age, sex, and race of the patient. The data elements are collected

Read the article Diagnosis Coding and Medical Necessity: Rules and Reimbursement by Janis Cogley located on the AHIMA Body of Knowledge (BOK) at http://www.ahima.org.

Quality physician documentation is not only essential to providing superior clinical communication, but also allows for the delivery of useful data that “supports quality metrics, acuity of care, billing, and accurate representation of medical conditions” (Rosenbaum et al., 2014). The Centers for Medicare and Medicaid Services (CMS) uses a system to classify Medicare patient’s hospital stays into various groups in order to facilitate payment of services called Medicare Severity-Diagnosis Related Group (MS-DRG). Some payers also use all patient refined (APR)-DRG reimbursement systems. MS-DRG groups are outlined by a specific collection of patient characteristics which include areas specific to the “principle diagnosis, specific secondary diagnoses,

We've had some major news stories about MA Plans overcharging lately. What exactly are they about?

Centers for Medicare and Medicaid Services (CMS) adopted the Medical Severity Diagnosis Related Groups (MS-DRGs) for use in the Inpatient Prospective Payment System (IPPS) in the fiscal year 2008, which ran from October 1, 2007 through September 30, 2008. CMS was influenced by the Medicare Payment Advisory Commission (MEDPAC) and the hospital community to use a severity adjusted DRG system.

The code set are said to be outdated and no longer meet the demand of healthcare, additionally ICD-9 cannot support many of the health IT and data exchange initiatives which made the implementation of ICD-10 an essential move. ICD-10 was implemented 1 October 2015 despite being one of the most feared events. The new system now saw Government agencies and payers provided with greater specificity on the conditions of the patients being treated (Conn & Herman, 2015). Additionally, it will also facilitate payers’ ability to profile specific providers, gauge outcome performance and adjust reimbursement based on the outcomes. Other improvement includes coding details connection with the data needs of accountable care organizations. Furthermore, there are a variety of conditions that were not uniquely defined in ICD-9-CM that now have an assigned code in ICD-10-CM. In the past, if a condition was not defined, coders had to determine the best way to code a condition, with the update, there will most likely be a specific code that will need to be used. Postoperative complication codes have been expanded. This will allow for distinction between intra and post-operative

➤ Diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all U.S. health care treatment settings. Diagnosis coding under this system uses 3–7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM

The article is about Diagnostic Related Grouping. The DRG primary duty is to decide on how Medicare and other insurance companies pay for hospital costs. For the DRG, it requires that hospitals are paid a fixed amount of cash prior providing health care to a given patient. Earlier on, hospitals used to compile the total money spend during the treatment of the patients. Most of the medical facilities used to include many minor expenses so as to get extra cash from the patient’s insurance cover. In some hospitals, patients used to be admitted for a longer time than usual so that the cost would increase for the purpose of benefiting the hospital. After noticing the behavior, the government came in and through the Medicare, patients diagnosed with the same condition are supposed to pay the same amount of cash despite the time he/she is admitted to the hospital (Elizabeth, 2017).

As we can see from this exercise medicare pays only $38 dollars per case which is well below the need $48 per case needed to cover the cost of of $40 and profit of $8 per case.  Therefore, prices must be set at a higher level to recuperate these cost plus revenue needed to maintain a profit. As Ge (2016) demonstrated, “Hospitals that treated a higher proportion of Medicare patients, had higher expenditures per adjusted discharge.”   Price must be set high enough so that insurer with discounts and self pay who only pay 60% of the charge, in addition fo cost patient, will generate enough revenue to offset the loss from medicare.  As McPike (2008) discussed, "This ...quantifies the 'hidden tax' that cost-shifting imposes on families and employers

In this framework, critical patients treated in ICU then to intermediate care and finally home care. At that time, first 2 segments were well received, but home care did not until 40 years later, then become an essential part of the long term care. She was one of the first people who formulated classification system for patient case and patient-oriented which is widely use in 21th century form: Diagnostic related groups of DRGs, which became the standard coding for

An AEP treating Medicare patients have the choice to either bulk bill patients or set their own fee for service rates. If the AEP chooses to bulk bill, Medicare publishes claim slips that can be used for the bulk billing of patients. If a fee is set and a gap payment is required to be paid by the patient directly to the AEP, an invoice is required to be provided to a patient for the services with all specific information for clients to they can claim back the amount from Medicare. The invoice used by the patient to claim back the rebate amount from Medicare must include: Patient name and details including Medicare number; Partitioners name and either: address of the place of practice from which services was provided or provider number for

In addition to the different prospective payment systems, diagnosis-related groups monitor quality of care and the uses of services in a hospital. Diagnosis-related groups are an “inpatient classification that categorizes patients who are similar in terms of diagnoses and treatment, age, resources used, and lengths of stay.” Diagnosis-related groups are important to how much reimbursement a healthcare

Identification number (structured data) which could be in a form of patient’s social security number, medicaid or medicare number, medical record number, drivers license number helps to further identify the patient. Discharge summary notes (unstructured data) summarizes the care that the patient received and that if the patient was stable before discharged. It involves the significant findings and hospital diagnosis, discharge condition and the arrangements and recommendations for future care. Physician progress notes (unstructured data) records details of the clinical service that was received from the physician during the course of hospitalization or over the course of outpatient care. A multidisciplinary note (unstructured data) involves professionals from diverse disciplines who came together to provide comprehensive assessment and consultation whiles the patient was

My last concern is management of my patient underlying comorbidities. For example my patient has diabetes and I think that his prolong uncontrolled blood sugar has led to his development of delayed gastric emptying. The prolong high blood sugar have possibly caused tissue and nerve damaged in the GI system. So I think it's important to help get his blood sugar manageable to help prevent further damage.

This is a more patient oriented model wherein the physician provides the patient with all the information that is relevant to his/her prevalent conditions. This includes, the state or criticality of the ailment, the nature or mode of diagnosis, the treatment or therapy recommended, the duration required for recovery, the cost involved in the treatment, the hazard or risks, if any. The physician basically gives a list of interventions from which the patient selects the intervention he/she feels worth taking.