3M Health Information Systems

APR-DRGs: A Practical Update

This Session Will Provide the Attendee with an Understanding of:

The development of APR-DRGs

The use of severity to define and compare a patient population

Application by agencies / associations

Current APR-DRG research & development

APR-DRGsAPR-DRGs

A tool to help analyze and report severity adjusted inpatient data

Developed by Healthcare Professionals for Healthcare Professionals

NACHRI PediatricDRG Modifications

MedicareDRG Updates

New YorkAP-DRG Expansion

Yale DRG Refinements

APR-DRGs

Evolution of the APR-DRG’s

The Use Of Inpatient Claims Data For Outcomes / Profiling studies

There are advantages to using of inpatient claims data for QI & UM management purposes:

With the implementation of Diagnosis Related Groups (DRGs) there is an extended period of experience with inpatient coding

As there are significant financial issues at stake for the hospital, there typically is considerable effort to code as accurately as possible

3M™ APR-DRG Assignment is Driven by:

Principal diagnosis

Procedures performed

All secondary diagnoses

Age, sex

Discharge disposition

DefinitionsDefinitions

• Severity of Illness: The extent of physiologic decompensation or organ system loss of function

• Risk of Mortality: The likelihood of dying

• Resource Intensity: The relative volume and types of diagnostic, therapeutic and bed services used in the management of a particular disease

APR-DRGAPR-DRG DescriptorsDescriptors

In the APR-DRG system a patient is assigned three distinct descriptors:

1. Base APR-DRG

2. One of four Severity of Illness subclasses

3. One of four Risk of Mortality subclasses

357 DRGs - 1422 Categories357 DRGs - 1422 Categories

3M™ APR-DRG Classification System

Subclasses are comparable within an APR-DRG but not betweenAPR-DRG’s.

Subclasses provide information regarding relative not absolute severity.

Level Severity * Level Mortality

1 Minor 1 Minor

2 Moderate 2 Moderate

3 Major 3 Major

4 Extreme 4 Extreme

Examples of Severity of Illness Levels

Examples of Standard Risk of Mortality Levels

APR-DRGs Are A Categorical Clinical Model

APR-DRGs are a clinical model that has been extensively refined with historical data

Different clinical models are developed for 355 different types of patients

Clinical models verified with data

Final decisions were always clinical

APR-DRGs are a Categorical Clinical Model (Cont’d.)

Expected values are computed using APR-DRG norms

Norms are average values of resource use or mortality for each APR-DRG subclass

An extensive set of APR-DRG norms are produced and updated annually

National / Regional / Hospital Type / Payer Specific

LevelLevel of Secondary Diagnosis for of Secondary Diagnosis for Severity of Illness and Risk of Mortality Severity of Illness and Risk of Mortality can be Differentcan be Different

A patient with acute cholecystitis has a A patient with acute cholecystitis has a

significant amount of organ decompensation, significant amount of organ decompensation,

but a low risk of dying:but a low risk of dying:

Severity of Illness:Severity of Illness: 33

Risk of Mortality:Risk of Mortality: 11

Level of Secondary Diagnosis for Severity of Illness and Risk of Mortality can be Different

• In general, except for malignancies and certain In general, except for malignancies and certain extreme acute diseases, the risk of mortality extreme acute diseases, the risk of mortality level is lower than the severity of illness levellevel is lower than the severity of illness level

• Traumatic amputation of arm, acute Traumatic amputation of arm, acute cholecystitis and acute osteomyelitis are a cholecystitis and acute osteomyelitis are a major severity of illness level but a minor risk of major severity of illness level but a minor risk of mortality levelmortality level

• Death is a relatively rare outcomeDeath is a relatively rare outcome

Outcome Measures which can be Examined Using APR-DRGs include:

Severity

Mortality

Certain types of complication rates

HCUP Quality Indicators

LOS

Charges

Readmission rates

Infection rates

Profiling outcomes and resource use

Measures which can be Examined Using APR-DRGs include:

Evaluating physician profiles for best practice models

Developing and supporting clinical pathways

Benchmarking

Improving accuracy of medical record coding/documentation

Negotiating managed care contracts

Responding to comparative data

Who Is Profiling Hospitals & Who Is Profiling Hospitals & Physicians?Physicians?

Federal/state regulatory agenciesJoint Commission on Accreditation of Healthcare OrganizationsHCFAPeer review organizationsManaged care payorsThird-party payorsProfiling agenciesHospitalsPhysician groupsState Health DepartmentsEmployersPublic-Internet

Actual Versus Expected Average Pharmacy Charge by Patient Severity Level:

Benchmarking Resources

0

500

1000

1500

2000

2500

3000

3500

4000

Min Mod Maj Ext

Facility

Norm

Determining Severity / Mortality Determining Severity / Mortality SubclassSubclass

• Determining the of subclass values uses a Determining the of subclass values uses a three phase processthree phase process

• The base APR-DRGs for severity of illness The base APR-DRGs for severity of illness and risk of mortality are the sameand risk of mortality are the same

APR-DRG Subclass Assignment

Phase 1: Determine the SOI / ROM level for each secondary diagnosis:

Phase 2: Determine the base SOI / ROM level for the patient:

Phase 3: Determine the final SOI / ROM level for the patient:

SOI = Severity of Illness

ROM = Risk of Mortality

Number of APR-DRGsNumber of APR-DRGs

• There are 355 base APR-DRGsThere are 355 base APR-DRGs

• Each APR-DRG is subdivided into four severity Each APR-DRG is subdivided into four severity of illness subclasses and four risk of mortality of illness subclasses and four risk of mortality subclassessubclasses

• In addition there are two error APR-DRGs In addition there are two error APR-DRGs (955,956) that are not subdivided into (955,956) that are not subdivided into subclassessubclasses

• The combination of APR-DRG and subclasses The combination of APR-DRG and subclasses results in 1422 APR-DRGsresults in 1422 APR-DRGs

APR-DRGs are the Most Widely Used Severity of Illness System

Agency for Research & Quality – HCUP II quality indicatorsSeveral payers evaluating for payment purposes22 states use APR-DRGs for public dissemination of provider profiles1400 individual hospitals have APR-DRG softwareMany major hospital groups and vendors have standardized on APR-DRGs

APR – DRG Clinical Research

Secondary DiagnosisComplication vs

Co-morbidity

UpdatesCode updates every October

Grouper update 2-3 years

Version 19 – scheduled release summer 2001

SummarySummary

• APR-DRGs can be used to identify utilization patterns

• APR-DRGs can be used to begin continuous quality improvement and outcome studies

• APR-DRGs provide a more effective basis for communicating with medical staffs

• APR-DRGs are an effective means of evaluating resources and outcomes data

• APR-DRGs are used in public release of data• APR-DRGs are continually being evaluated

and improved

APR-DRG data in TRENDSTAR

TRENDSTARTRENDSTAR TRENDSTARTRENDSTAR

Patient Data sent to the PC

for APR-DRG Grouping

22

11

Patient record updated with: •APR-DRG Code•Severity of Illness Code •Mortality code

3M APR-DRG Grouper Installed on local PC

Uses of APR-DRG Information

Patients adjusted for severity

Comparative data among hospitals

Examine mortality rates based on mortality risk assignment

Development of clinical pathways

Quality improvement initiatives

Contract negotiation

Identification of disproportionate share of major and extreme severity levels

Analysis of net income for APR-DRGs based on severity levels