DRG

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???????????????????? (DRG) ????????

• DRG ????????????????????????????????????
  (Patient Classification System)
  ??????????????????????? ??????????????????????????
  ?? ?????????????????????? ????????????????????????
  ??????????? ????????????????????? ????????????
  (Iso-resource group)

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???????????????? DRG

• ???????????????????????? fee-for-service
  ?????????
• ???????????????????????? capitation
  ?????????????????????

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????????????????????????????

• DRG ??????????? USA ??????? Medicare
  ????????????????????????????????
  ?????????????????????? (Prospective Payment
  System) (Fetter R et al 1980)

4
???????????

• Complication ????????????
• Comorbidity ??????????????????????
• CC Complication or Comorbidity ???????????????????
  ?????????? 1 ??? ??????
• HCFA Health Care Financing Administration
  ???????????????????????????????????????

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???????????

• LOS Length of Stay
• MDC Major Diagnostic Category ?????? ? ??? DRG
  ???????????????? ? ??????????
• OR Operating Room
• OT Outlier Trim Point ??????????????????

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???????????

• PDx Principle Diagnosis
• SDx Secondary Diagnosis
• RW Relative Weight ???????????????
• Grouper ??????????????????????? DRG
• Drgaudit ??????????????????????? DRG

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?????????????????????????? DRG

• ????????????????????????
• diagnosis codes, procedure codes, LOS, age, sex,
  etc.
• ??????????????????????????????
• size, teaching status, location...
• ????????????????????????
• physicians salaries, food, pharmacy...

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??????????????????????????

• ??????????? (ICD-9-CM/10 diagnosis codes)
• ????????? (ICD-9-CM procedure codes)
• ??????????????????????
• ????
• ?????????????? (neonates)
• ?????????????????

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DRG Systems

• Medicare HCFA-DRGs
• Includes Multiple Trauma, Transplants,
  Tracheostomy. Focus on Over 65
• All Patient AP-DRGs
• Adds DRGs for Newborns, Major Complications and
  Comorbidities, Intended for a General Population
• All Patient Refined APR-DRGs
• Based on AP-DRGs,Yale Refinements, HCFA updates -
  Adds Four Severity Levels Based on Severity of
  Illness Risk of Mortality, and Resource
  Intensity--Minor, Moderate, Major, Extreme

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(No Transcript)
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???????? DRG version 1

• ?????????????? ICD9CM ?????? ICD10
• GROUPER ?????????? SOURCE CODE
• GROUPER ????????????? ??????????????
• ???????? UPDATE
• ????????????????????
• ?????????????????? 490 ?????

12
????????? DRG( DRG Grouping Algorithm )
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PDx SDx, Proc Age, Sex, D/C Type
GROUPER
DRG
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PDx Principal Diagnosis ???????
????????????????? ?? 1 diagnosis ????????
SDx Secondary Diagnosis ???????? (???
active) ???? ???????
???????????? ????? 0 diagnosis ???????????
15
Proc Procedures ?????????/??????? ????? 0
procedure ???????????
- Operating Room Procedures - Non-operating Room
Procedures - Procedure Combinations
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Age 0 - 124Sex 1 male, 2 female
Discharge Type 1 with approval 2
against advice 3 escape 4
transfer 8,9 dead
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PDx,SDx, Proc,Age, Sex, D/C Type
MDC DC DRG
1
2
DRG
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Grouper Algorithm (HCFA v. 17)
Pre MDC Proc
MDC 24 PDx SDx
MDC 25 PDx SDx
MDC 1 - 23 PDx
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Pre MDC
All Patients
Yes
Tracheostomy w PDx except Face Mouth Neck Dx
483
12.7400
No
Yes
Liver Transplant
480
7.3942
No
Yes
Lung Transplant
495
8.8332
No
BM Transplant
Yes
481
8.7285
No
Yes
482
Tracheostomy w PDx Face Mouth Neck Dx
4.8883
No
No
Yes
482
4.8883
Total Laryngectomy
No
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CASE 1
??? ???? 35 ???????????????? (K746)
?????????.???? 20 ??? ??????????????? ?? Liver
Transplantation (5059)
MDC ?
21
CASE 1
PDx K746 SDx - Proc 5059 Age 35
Sex 1
Proc 5059 gt Pre MDC
?????????? 3
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Grouper Algorithm (HCFA v. 17)
Pre MDC Proc
MDC 24 PDx SDx
MDC 25 PDx SDx
MDC 1 - 23 PDx
23
MDC 24
A
1. PDx Trauma Dx 2. gt 2 Different
Significant Sites 3. gt 3 Trauma Dx
Yes
MDC 24
No
B
24
CASE 2
??? ???? 28 ?? ??? MC ?????????? ?????
?????.?????????????????? ???????????????????? 3
????????????. ?????????????????
PDx Diffuse brain injury (S0620) SDx 1.
Fracture vault of skull, closed (S0200) 2.
Fracture base of skull, closed (S0210) 3.
Fracture of femur, right side (S729) Proc none
MDC ?
25
CASE 2
PDx S0620 SDx S0200, S0210, S729 Proc - Age
28 Sex 1 D/C Type 8
PDx Trauma gt MDC 24 ?
?????????? 280-288
No Proc gt Not Pre MDC
S0620 gt Site 1, S0200 gt Site 0 S0210 gt Site
0, S729 gt Site 8
PDx Trauma ,gt3 Trauma Dx, 2 Sign Sites
gt MDC 24
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Grouper Algorithm (HCFA v. 17)
Pre MDC Proc
MDC 24 PDx SDx
MDC 25 PDx SDx
MDC 1 - 23 PDx
27
MDC 25
B
PDx of HIV Disease OR SDx of HIV Disease and
PDx of Significant HIV Related Condition
MDC 25
Yes
No
MDC 1 - 23
28
CASE 3
???????? 29 ?? ???????????????????.
?????? ????????????? ????? ?? ????? ??????.
10 ??? ????????????????????????? ????????
PDx HIV disease result in Pneumocystis
carinii pneumonia (B206) SDx Oral candidiasis
(B370) Proc none
MDC ?
29
CASE 3
PDx B206 SDx Oral candidiasis (B370) Proc
- Age 29 Sex 2 D/C Type 1
No Proc gt Not Pre MDC
PDx B206 Not Trauma Dx gt Not MDC 24
PDx B206 gt MDC 25
?????????? 304-309
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Grouper Algorithm (HCFA v. 17)
Pre MDC Proc
MDC 24 PDx SDx
MDC 25 PDx SDx
MDC 1 - 23 PDx
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CASE 4
??????? 18 ?? ??? MC ??????????
???????? ??.??????????????????
????????????????????? ??????. 20 ???
??????????????????????? ??
PDx Epidural hemorrhage (S064) SDx 1. Fracture
vault of skull, closed (S0200) 2. Fracture base
of skull, closed (S0210) Proc Craniotomy with
removal of epidural hematoma ( 0124 )
MDC ?
32
CASE 4
PDx S064 SDx S0200, S0210 Proc 0124 Age
18 Sex 1 D/c Type 1
Proc 0124 gt Not Pre MDC
PDx Trauma gt MDC 24 ?
S064 Site 1, S0200 Site 0, S0210 Site 0
gt Not MDC 24
PDx S064 MDC 1
????????? 44
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??????????????????? MDC
1. ?? Proc ??? Pre MDC ??????? 2. PDx ???? Trauma
??????? MDC 24 ??????? 3. PDx ???? HIV Infection
???? Sign. HIV Related Cond. ??????? MDC 25
??????? 4. PDx ???? MDC ?? ?? MDC 1 -
23 ???????????? MDC ?????????????? (????????? 5)
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????? MDC ???
1. Pre MDC Assignment of ICD-9-CM Codes 2. MDC 24
Definition Definition of Trauma Diagnosis
and Sig. Body Sites Categories 3. MDC 25 Def.
Def. Of Sig. HIV Rel. Cond. MDC 25
Assignment of ICD-10 Codes 4. MDC 1 - 23
Assignment of ICD-10 Codes (
???????????????????????????)
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MDC gt DRG
1. ????? Diagram ???????? MDC Diagram
???????????????????? 2. ??? Proc / PDx ?? DC
???????? ?????? Assignment... 3. DC gt DRG
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DC (Disease Cluster)
?????????/???????????????????????????
ICD-10
MDC 2
MDC 3
MDC 1
MDC...
Dx
DC9
DC10
DC12
DC...
Proc
DC1
DC4
DC5
DC...
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????? DC
1. Diagram ????? ????????????? - ???????? Proc
ICD-9-CM Assign. - ???????? PDx ICD-10
Assign. (14,15,17,20,22,25) 2. Surgical
Hierarchy (App. D) 3. Unrelated OR Procedures
(App. B) 4. Procedure Combinations (App. C)
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DCgtDRG
?? 2 ??? 1. ??????? - DRG DC - Age /or
CC 2. ?????????? AX, D/C Type
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DCgtDRG
1. Diagram ?????????? 2. ??????????? - DRG
Definitions - DC, AX Def. (App. A)
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CC
(Complications or Comorbidities)
Appendix F ??????????
1. Dx Defined as CC (CC List)
???????????????????? ??????????? 2. Exclusion
List ??????????? ??? CC List
???? CC ?? Exclusion List ?????????
41
?????? CC
1. ?? SDx ??????????????? CC List ??????? ??????
gt ??????? CC 2. ??????? -gt ????? PDx ??????
Exclusion List ??????? ??????? gt ???????
CC ?????????? gt ???? CC 3. ????????????? CC
???????????? SDx
42
CASE 1
??? ???? 35 ???????????????? (K746)
?????????.???? 20 ??? ??????????????? ?? Liver
Transplantation (5059)
DRG ?
43
CASE 1
3,280,304
PDx K746 SDx - Proc 5059 Age 35
Sex 1
Proc 5059
gt Pre MDC DRG 480
44
CASE 2
??? ???? 28 ?? ??? MC ?????????? ?????
?????.?????????????????? ???????????????????? 3
????????????. ?????????????????
PDx Diffuse brain injury (S0620) SDx 1.
Fracture vault of skull, closed (S0200) 2.
Fracture base of skull, closed (S0210) 3.
Fracture of femur, right side (S729) Proc none
DRG ?
45
CASE 2
3,280,304
PDx S0620 SDx S0200, S0210, S729 Proc - Age
28 Sex 1 D/C Type 8
No Proc gt Not Pre MDC
PDx Trauma gt MDC 24 ?
S0620 gt Site 1, S0200 gt Site 0 S0210 gt Site
0, S729 gt Site 8
PDx Trauma, gt3 Trauma Dx, 2 Sign Sites
gt MDC 24 DRG 487
46
CASE 3
???????? 29 ?? ???????????????????.
?????? ????????????? ????? ?? ????? ??????.
10 ??? ????????????????????????? ????????
PDx HIV disease result in Pneumocystis
carinii pneumonia (B206) SDx Oral candidiasis
(B370) Proc none
DRG ?
47
CASE 3
3,280,304
PDx B206 SDx Oral candidiasis (B370) Proc
- Age 29 Sex 2 D/C Type 1
No Proc gt Not Pre MDC
PDx B206 Not Trauma Dx gt Not MDC 24
PDx B206 gt MDC 25
No Extensive OR Proc
PDx B206 gt AX 489x
gt DRG 489
SDx B370 gt AX 489x
48
CASE 4
??????? 18 ?? ??? MC ??????????
???????? ??.??????????????????
????????????????????? ??????. 20 ???
??????????????????????? ??
PDx Epidural hemorrhage (S064) SDx 1. Fracture
vault of skull, closed (S0200) 2. Fracture base
of skull, closed (S0210) Proc Craniotomy with
removal of epidural hematoma ( 0124 )
DRG ?
49
CASE 4
3,280,304
PDx S064 SDx S0200, S0210 Proc 0124 Age
18 Sex 1 D/c Type 1
PDx Trauma gt MDC 24 ?
S064 Site 1, S0200 Site 0, S0210 Site 0
gt Not MDC 24
PDx S064 MDC 1 (????? ???? 44)
MDC 1 Proc 0124 DC 1
DC 1 Age gt 17, PDx in AX 2 gt DRG 2
50
CASE 5
3,280,304
PDx H259 SDx E118 Proc
1341 Age 70 Sex M D/C
Type 1
Proc 1341 gt Not Pre MDC
PDx H259 gt Not Trauma, Not HIV gt MDC 2
(????? ???? 18)
MDC 2 Proc 1341 gt DC 39
DC 39 gt DRG 39
51
CASE 6
3,280,304
PDx J13 SDx E102 Proc
- Sex F D/C Type 1
Age 22
X
X
PDx Trauma Dx ? HIV/HIV Related ?
89
04
PDx J13 gt MDC ? DC ?
Yes
SDx E102 gt CC ?
DRG ?
DRG 89
52
CASE 7
3,280,304
PDx J13 SDx E119 Proc
- Sex M D/C Type 1
Age 45
X
X
PDx Trauma Dx ? HIV/HIV Related ?
04
89
PDx J13 gt MDC ? DC ?
No
SDx E119 gt CC ?
DRG ?
DRG 90
53
CASE 8
3,280,304
PDx I019 (Ac Rh H Dis) SDx
J47 (MS w MR), E119 (NIDDM wo C) Proc
None Age 35 Sex F D/C
Type 1
PDx I019 (Ac Rh H Dis) SDx
I052 (MS w MR), E119 (NIDDM wo C) Proc
None Age 35 Sex F D/C
Type 1
PDx I019gtMDC 5 DC 144 (????? 20)
SDx I052 gt CC ?
gt No
gt No
SDx E119 gt CC ?
DC 144 wo CC gt DRG 145
54
CASE 9
3,280,304
PDx K565 (Int. Adhesion w Obs)
SDx - Proc 5459,4709,4562 Age 32
Sex M D/C Type 1
PDx K565 gt MDC 6 (????? 23)
SH 4.0 5.0 2.0
Proc 5459 gt DC 150 4709 gt DC 166 4562
gt DC 148
DC 148 , No CC gt DRG 149
55
Unrelated OR Procedures (App. B)
?????? DRG
1. ?????????????? Unrelated ??? Proc. ??????? 2.
?????????????? OR Proc ??????? 3. ????????? Proc.
?? DC 476 ??? 477 ??????????????? ?????? gt DRG
468 4. ?????? ??????? Proc. ?? DC 476 ???????
????? gt DRG 476 ???????? gt DRG 477
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(Prostatic or Non Extensive Procedures)
Prostatic Procedure
57
CASE 10
3,280,304
PDx R040 SDx I10 Proc
6069 Age 65 Sex M D/C
Type 1
PDx R040 gt MDC 3 (????? 43)
Proc 6069 gt Not in MDC 3 gt Unrelated
App. B 6069 gt DC 476
gt DRG 476
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CASE 11
PDx N393 SDx N301 Proc
- Age 48 Sex D/C Type

PDx N393 gt (????? 36,5)
M MDC 11 F MDC 13
Need Sex Data BUT No Sex Data
DRG 470
59
???????????????? ???????????? Computer
CHART
???? ICD10
???? DRG
MRA

• Physician discharge summary
• Informed consent
• History
• Physical examination
• Progress note
• Operative note

• Anesthetic record
• Labour record
• Consultation record
• Rehabilitation record
• Nurses note

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???????? DRG

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