Diagnosis Related Groups (DRGs)

Diagnosis Related Group DRG Diagnosis Related Group. A "Diagnosis Related Group"

is a payment category that is used to classify patients,

especially Medicare patients, for the purpose of reimbursing

hospitals for each case in a given category with a fixed fee

regardless of the actual costs incurred. A DRG is based upon

the principal ICD-9-CM diagnosis code, ICD-9-CM surgical

procedure code, age of patient, and expected length of stay in

the hospital that will be reimbursed, independently of the

charges that the hospital may have incurred

DRG OVERVIEW:

The American health care system was quite different than it is today.  Back in the 1950s not everyone had health insurance, mostly those who did had either private insurance or BC/BS (Blue Cross/Blue Shield).  In the 1960s Medicare and Medicaid was created. 

In the 1970s, there was a lot of distrust for the U.S. government including lack of confidence in the American medical system.  There were many without insurance and a great number of companies did not offer health care benefits.  President Nixon created Managed Care Organizations (MCOs), which required companies to provide health insurance for their employees.  

What really transformed is the way in which inpatient health care would be reimbursed in the 1980s.  Health care costs were out of control.  Facilities were being reimbursed for what services they provided regardless of cost (fee for service or time rendered) and there was no incentive for them to streamline costs.  Congress implemented the UB-82 (now UB-92) to create one claim form for all insurance agencies for inpatient services.   The DRG system was created in 1983 to cut costs for Medicare patients.  The DRG system is a patient classification system that groups patients with similar diagnoses and/or procedures into the same category.  The facility is then reimbursed with a lump sum payment based on this category, figuring on average what it would cost to treat a patient with a diagnosis.  Congress also required that facilities have an active Utilization Review and Quality Assurance Department to evaluate the quality of care patients are receiving and how that care is utilized (how much resources are used) to care for the patient.

History In the mid 1970s the Centre for Health Studie

s at Yale University began work on a system f

or monitoring hospital utilisation review. Follo

wing a 1976 trial of a DRG system, it was dec

ided to base the final system on the ICD-9-C

M which would provide the basic diagnostic c

ategories

Purpose. relate a patient’s diagnosis and treatment to the

cost of their care Developed in the United States by the Health C

are Finance Administration DRGs are used for reimbursement in the prosp

ective payment system of US Medicare and Medicaid healthcare insurance systems

DRGs were designed to support the calculation of federal reimbursement for healthcare delivered through the U.S. Medicare system

A patient’s principal diagnoses and the procedures they are treated with during hospital admission are used to select the group in the DRG classification that most appropriately describes they overall type of care that has been delivered.

Diagnosis Related Groups (DRG) are a system classifying in-hospital patient cases into categories with similar resource use. The grouping is based on diagnoses, procedures performed, age, sex and status at discharge

Next the group selected is associated with a typical cost. Specifically, DRG funding requires the use of a cost weighting that is applied by the funding agency to determine the actual amount that should be paid to an institution for treating a patient with a particular DRG. The weightings are determined by a formula that is typically developed on a state or national basis.

DRG Structure Major Diagnostic category

Medical Surgical split

Complications & Comorbidities

Exclusion list

Structure diagram

DRG Example with severity score

Major Diagnostic Category Assignment (MDC)

The initial step in the determination of the DRG has always been the assignment to the appropriate MDC based on the Principal Diagnosis

Since the presence of a surgical procedure requires different hospital resources (operating room, recovery room, anesthesia) most MDCs were initially divided into medical and surgical groups

Medical Surgical split

All procedure codes were classified based on whether or not they required the use of an operating room

Operating room procedures – Cholecystectomies

– Cerebral meninges biopsies– Closed heart valvotomies

Non operating room procedures – Bronchoscopy

– Skin sutures

Complications & Comorbidities (CCs)

A complication is a condition which did not exist prior to the admission

A comorbidity is a condition which existed prior to admission

A complication or comorbidity is a secondary diagnosis which would be expected to extend the patient’s length of stay by at least one day in at least 75 percent of patients

Major CCs Within each MDC patients with major CCs

(e.g., AMI, CVA, etc.) were assigned to separate DRGs, and as part of the Severity Level process of IR-DRGs

A major complication or comorbidity is a secondary diagnosis which would be expected to extend the patient’s length of stay by at least 3-4 days in at least 75 percent of patients

Complication & Comorbidity(CC) Exclusion List

For a principal diagnosis of bladder neck obstruction

– Urinary retention is not a CC For a principal diagnosis of general

convulsive epilepsy – Convulsion is not a CC

DRG Classification - Example Principal Diagnosis 41091: AMI NOS, Initial MDC 5

Diseases and Disorders of the Circulatory System Operating Room Procedure 3761:Pulsation Balloon

Implant DRG 110: Major Cardiovascular Procedures with CC

orDRG 111: Major Cardiovascular Procedures without CC orDRG 549: Major Cardiovascular Procedures with Major CC

Secondary Diagnosis 1) 25000: Diabetes Mellitus Type II without

Complications - CC : No - Major CC : No - DRG : 111

DRG Classification - Example 2 Principal Diagnosis 41091: AMI NOS, Initial MDC 5 Diseases and Disorders of the Circulatory System Operating Room Procedure 3761:Pulsation Balloon Implant DRG 110: Major Cardiovascular Procedures with CC or

DRG 111: Major Cardiovascular Procedures without CC orDRG 549: Major Cardiovascular Procedures with Major CC

Secondary Diagnosis1) V434: Blood Vessel Replacement Not Elsewhere Classified (NEC)

- CC : No - Major CC : No 2) 7100: Systemic Lupus Erythematosus - CC : Yes - Major CC : No - DRG: 110

DRG Classification - Example 3 Principal Diagnosis 41091: AMI NOS, Initial

MDC 5 Diseases and Disorders of the Circulatory System

Operating Room Procedure 3761:Pulsation Balloon Implant DRG 110: Major Cardiovascular Procedures with CC or

DRG 111: Major Cardiovascular Procedures without CC or

DRG 549: Major Cardiovascular Procedures with Major CC

Secondary Diagnosis

1) 78551: Cardiogenic Shock

- CC : No

- Major CC : Yes

- DRG : 549

Surgical Hierarchy

If multiple procedures are present, the patient is assigned to a single surgical DRG based on a surgical hierarchy within each MDC

DRG Structure كلي :3از DRGساختار از عبارتند كه شده تشكيل جزءPreMDC كه همان قسمت استثناء DRG است MDCكه همان قسمت اصلي است ErrorDRG .كه از نظر اطالعات بهداشتي ناقص است

به عبارت ديگر يا اطالعات موجود در پرونده متناقض يا غير معتبر است و يا تشخيص گزارش شده دقيق و كامل

خاصي به آن اختصاص داد. DRGنيست و نمي توان كد اين كدها عبارتند از:

به: 468كد • و شود بستري بيمارستان در علتي به بيماري اگرگيرد،كد قرار جراحي عمل مورد ديگري آن DRG468علت به

. نارسايي اصلي تشخيص با كه بيماري مثال يابد مي اختصاصبه رو صفراي كيسه التهاب بدليل اما شده بستري قلب احتقاني

وي براي صفرا كيسه ساختن خارج جراحي اقدام ، پيشرفت. است شده انجام

كد • با .DRG 470باشد شود مي مشخص

DRG Structureكافي: 469كد • اندازه به شده انتخاب اصلي تشخيص كه زماني

از خاصي كد بتوان تا نيست درست و بيمار DRGدقيق به را . از كدي اگر حتي شود مي استفاده كد اين از داد اختصاص

ICD . كد مثال شود گرفته نظر در مورد آن در 646.90برايICD-9-CM ،زايمان از پيش نامشخص عوارض دهندة نشان

. در است زايمان از پس و زايمان اطالعات DRGهنگام بايداست شده ايجاد عارضه مراقبت از مرحله كدام در دهد نشان

كد نباشد، مشخص كه صورتي در اختصاص DRG 469و آن به. يابد مي

ممكن: 470كد • كه پزشكي هاي گزارش در شده ثبت اشتباهاتكد تخصيص بر مي DRGاست مشخص كد اين با بگذارد اثر

وي. سن گزارشات در كه بيماري مثال گزارش 154شود سالداشته بستگي بيمار سن با كد انتخاب كه صورتي در شده،

DRG assignment The first step in DRG assignment is the classification of

discharges by Major Diagnostic Category (MDC). There are

25 MDCs which are essentially primary diagnostic groupings

generally based on the body systems, e.g. nervous system

(MDC 1), eye (MDC 2), circulatory system (MDC 5), etc.

There are some exceptions where the classification by MDC

does not follow this pattern, for example MDC 14:

Pregnancy, Childbirth, and the Puerperium, MDC 24:

Multiple Trauma, and MDC25: HIV Infection.

Following assignment to the MDC, discharges are assigned

to the DRG level. Discharges with a surgical procedure

performed are assigned to the surgical DRGs where

classification is based on the most resource intensive

procedure

performed. Medical discharges are assigned to a DRG on the basis of the principal diagnosis. Further classification within these groups arise if particular variables, like the presence of complications/comorbidities (ccs), age, or discharge status are found to have a significant influence on the treatment process and/or the pattern of resource utilisation.Some exceptions to the general approach for DRG classification do exist, for example, discharges receiving liver or bone marrow transplants and discharges with temporary tracheostomies being assigned to DRGs outside of the MDC framework

DRG assignment

A DRG is assigned based on the patient's diagnosis (ICD-9-CM coding).  The encoder (also known as the DRG grouper) is a software program developed by CMS that places the patient into a Major Diagnostic Category based on the diagnosis.  

For example:  A patient with a fracture  would be grouped to the Musculoskeletal Major Diagnostic Category.  At this point, the patient is considered a medical DRG.  If the patient has a surgical procedure, then the patient is grouped to a surgical DRG.  The other factors that influence DRG assignment is age of the patient, any complication/comorbidities, and discharge status.  

Illustration of DRG-grouping, patient > 17 years

Major diagnosis ICD10 S72.0:Fracture of the collum femoris

DRG 236:Hip/pelvisfracture

DRG 211:Hip/thigh bone

operation

DRG 213:Amputations

DRG 210:Hip/thigh bone

operation

DRG 216:Biopsies

(rheumatic diseases)

BiopsyNCSP 50

Marrow nailingAmputation

MDC 08:Rheumatic diseases

Surgical procedures

Type of surgery

Secondarydiagnosis

YesNo

Yes

DRG assignment

كدهايICD گروه در تخصص يا بدن هاي سيستم اساس بر

اصلي تشخيصي .[1]هاي گيرند مي قرار

گروه در اند شده مرخص جراحي عمل از پس كه افرادي

گروه در اند نداشته جراحي عمل كه كساني و جراحي

. گيرند مي قرار پزشكي

ميزان اساس بر گيرند مي قرار جراحي گروه در كه كساني

. كه بيماراني شوند مي تقسيم گروه چند به منابع مصرف

جراحي ترين پرهزينه اساس بر اند، داشته جراحي عمل چند

. ديالتاسيون و كورتاژ اقدام اگر مثال شوند مي بندي [2]طبقه

رحم كردن خارج انجام [3]و بيمار روي بر همزمان بطور

به دارد، بيشتري تدابير به نياز رحم ذرآوردن چون شود،

. شود مي انتخاب تر هزينه پر اقدام عنوان

DRG assignment تشخيص اساس بر اند گرفته قرار پزشكي گروه در كه كساني

. ... شوند مي تقسيم و نئوپالسم مانند فرعي هاي گروه به اصلي

توسط و مشابه هاي روش به كه بيماراني ها گروه اين در

گروه يك در شوند، مي درمان مشابه مي DRGمتخصصين قرار

گيرند.

هاي بيماري ، عوارض اصلي، تشخيص از نهايي بندي گروه براي

مرده، ( ترخيص هنگام وضعيت و بيمار جنس بيمار، سن ، همراه

( كنند مي استفاده بعدي پيگيري .زنده،

[1] Major Diagnostic Category (MDC) [2] Dilatation & Curettage (D&C) [3] Hysterectomy

Example

( ) و بزرگسالي در شروع ديابت تشخيص با بيماري . هاي پيگيري است شده پذيرش شكمي حاد كوليك . براي است داده نشان را صفرا كيسه سنگ بعديمجاري جستجوي و صفرا كيسه كردن خارج بيمار

. مدت اغلب بيمار ديابت است شده انجام صفراوياست داشته اقامت بيمارستان در بيمار كه زماني

. است بوده كنترل از خارج - و صفراوي كبدي سيستم درگير، بدني سيستم

. است بوده جراحي چپانكراس عمل بيمار برروي ونشود مي محسوب جراحي اقدام است، شده انجام. است نداشته همزمان بيماري يا عوارض هيچگونه و

DRG information for DRG-production and DRG-reimbursement

Payment calculation و ها تشخيص تمامي پزشك بيمار، شدن مرخص از پس

. كند مي ثبت مخصوص فرم روي را ها درمان مناسب كد مي ICD-9-CMسپس ثبت و تعيين كدگذار توسط

شود. مي فراهم را صورتحساب فرم بيمارستان حسابداري بخش

كدهاي بيمار، هويتي اطالعات فرم درآن كه و ICD-9-CMكند . شود مي ثبت اطالعات ساير

مورد ليست يا صورتحساب مالي كارگزاران بعد مرحله درآنها بودن صحيح و كدها تناسب و بودن خوانا ازجهت را نظر

كدهاي اساس بر و كنند مي DRGكد ICD-9-CMبررسي . شود مي تعيين

گروه و DRGهر خدمات كليه هزينه كه دارد نسبي ارزش يك . هرچه كند مي منعكس را بيمار براي شده مصرف تجهيزاتهزينه و شده مصرف بيشتري منابع باشد بيشتر ارزش اين

. گروه هر نسبي ارزش يابد مي افزايش در DRGبيمار . است يكسان مشابه هاي بيمارستان

[1] Hospital rate

Payment calculation بر بيمارستان هر در بيمارستاني هزينه پرداخت مقدار

جغرافيايي، بيمارستان، نوع نظير مختلف عوامل اساسنرخ اختالف بيمارستان، بودن شهري يا روستايي

هزينه بر كه عواملي ساير و مختلف نواحي در دستمزدبيمارستاني نرخ مقدار اين ، شود مي تعيين دارند 1]تاثير

اساس [ بر مختلف سالهاي در است ممكن كه دارد نام . تخت تعداد و آموزشي وضعيت قبال كند تغيير تورم نرخامروزه ولي ، آمد مي بحساب ها هزينه محاسبه در نيز

. است شده رد عوامل اين تاثير در بيمارستاني نرخ حاصلضرب از بيماران هزينه لذا

. مبلغ بيمارستان ترتيب اين به آيد مي بدست ثابت هزينهكمتر بيمار هزينه كه درصورتي ، كند مي دريافت را ثابتي

مابه تواند مي بيمارستان باشد، دريافتي هزينه ازچنانچه عكس بر و نمايد ذخيره سود بعنوان را التفاوت

مبلغ از بيشتر بيمار براي شده صرف باشد، DRGهزينه . شود متحمل را وارده خسارات است مجبور بيمارستانسودمند بيماران ، ها بيمارستان شود مي باعث امر اين

خودداري آور زيان بيماران درمان از و كنند انتخاب راكنند.

CODING AND ITS RELATION TO DRG ASSIGNMENT Coding is a team approach.  If there is improper

documentation the facility, along with the physician, are considered noncompliant in reflecting the patient's true hospital course.  Coding can only be done in an accurate, timely, and ethical manner by using conclusive documentation by physicians.  

It is the role of the coder to go through the whole medical record to locate all the information to accurately code including ethically coding complications and comorbidities.  These conditions can be found in various placed in the medical record.  The medical record needs to be comprehensive, legible, well-documented, and completed in a timely fashion to be compliant.  Lacking any of these will place the facility in danger of being audited, increasing the risk of fraud and abuse.

Inpatient Classification Objectives

Aid in Clinical Management

Provide Equitable Resource Allocation Method

Promote Efficiency & Effectiveness in Managing Inpatient Care

Increase Accuracy in Reporting Workload and Associated Costs

Develop a classification system that is the basis for

Hospital Management

Budgeting

Benchmarking Profiling

Clinical research

Quality reporting

Global comparison

Payment

Level of acceptance and use DRGs are used routinely in the United

States for management review and payment for Medicare and Medicaid patients. Given the importance of reimbursement world-wide, DRGs have undergone ongoing development, and have been adopted in one form or another in many countries outside the USA, including Australia (AR-DRG), Canada (CMG) and countries of Europe and Asia.

Classification structure Patients are initially assigned a code from ICD-9 CM or a cli

nical modification of ICD-10. ICD clinical modifications are multiaxial systems closely based on the ICD structure. Diagnoses are then partitioned into one of about 25 Major Diagnostic Categories (MDCs) according to body organ system or disease. The aim of this step is to group codes into similar categories that reflect consumption of resources and treatment .The categories are next partitioned based upon the performance of procedures, and on other variables such as the presence of complications and co-morbidities, patient age, and length of stay, before a DRG is finally assigned .There is thus a process of category reduction at each stage, starting from the many thousands of ICD codes to the few hundred DRGs:

ICD MDC DRG)

Limitations DRGs and case-mix indices will always only give approximate estimates of the true resource utilisation. For example, should a hospital that is developing new and expensive procedures be paid the same amount as an institution that treats the same type of patient with a more common and cheaper procedure? Should quality of care be reflected in a DRG? For example, if a hospital delivers good quality of care that results in better patient outcomes, should it be paid the same as a hospital that performs more poorly for the same type of patient? As importantly, those institutions that are best able to create DRGs accurately are more likely to receive reimbursement in line with their true expenditure on care. There is thus an implication in the DRG model that an institution actually has the ability to accurately assemble information to derive DRGs and a case-mix index. Given local and national variations in information systems and coding practice, it is likely that institutions with poor information systems will be disadvantaged.

Developments DRGs are designed for use with inpatients. Accordingly, ot

her systems have been developed for other areas of healt

hcare. Systems such as Ambulatory Visit Groups (AVGs)

and Ambulatory Payment Classifications (APCs) have bee

n developed for outpatient or ambulatory care in the prima

ry sector. These are based upon a patient’s diagnosis, inte

rvention, visit status and physician time.

The DRG Handbook, 2003

DRG auditsDRG audits may consists of evaluating

those DRGs that are incorrectly used.  These audits may also focus on missing diagnoses, missing procedures, and incorrect principal diagnosis selection

For DRG based reviews, cases may be selected in a variety of ways: • Simple random sample • High dollar and high volume DRGs • DRGs without comorbid conditions or complications • Focused DRGs such as DRG 79 Pneumonia or DRG 416 Septicemia

and other high risk DRGs • Correct designation of patient discharge and transfer status

CPT auditsFor physician services, hospital outpatient services, and

freestanding ambulatory surgery

centers, audits may focus on the following:

• Evaluation and management services for physician visits

• High volume and/or low volume outpatient surgeries

• Use of CPT modifiers on physician and outpatient claims

• Unlisted CPT codes

• Diagnosis codes on outpatient claims for medical

necessity of diagnostic services

• Accurate use of ICD-9-CM and CPT for ambulatory

surgery services

Ten DRGs with the highest rates of upcoding

In its August 1998 report, Using Software to Detect Upcoding of Hospital Bills, the Office of Inspector General lists the following diagnosis-related groups as having the highest rates of upcoding.

87-pulmonary edema and respiratory failure 79-respiratory infections and inflammations with complicating

conditions (cc) 144-other circulatory system diagnoses with cc 239-pathological fractures and musculoskeletal and connective

tissue malignancy 429-organic disturbances and mental retardation 416-septicemia 475-respiratory system diagnosis with ventilator support 188-other digestive system diagnoses with cc 121-circulatory disorders with acute myocardial infarction and

cardiovascular complications, discharged alive 316-renal failure

case-mix DRGs are also used to determine an

institution’s overall case-mix. The case-mix index helps to take account of the types of patient an individual institution sees, and estimates their severity of illness. Thus a hospital seeing the same proportion of patients as another, but dealing with more severe illness, will have a higher case-mix index

An institution’s case-mix index can then be used in the formula that determines reimbursement per individual DRG

Case mix calculation ) مثال خاص زماني دوره يك در بيمارستان به كننده مراجعه بيماران

گروه) چه در بيمار هر كنيم مي مشخص و گيريم مي نظر در را يكسالDRG . گروه هر بيماران تعداد سپس است گرفته ارزش DRGقرار در را

. جمع يكديگر با را مقادير اين سپس كنيم مي ضرب گروه همان نسبي . قدر هر كنيم مي تقسيم خاص دوره آن در بيماران كل تعداد بر و كرده

بوده بيشتر بيمار هر براي شده تمام هزينه باشد، بزرگتر آمده بدست عدد. است داده ارائه را تري ارزنده خدمات بيمارستان ديگر بعبارت و

:، خاص زماني دوره يك در كرده 1000مثال مراجعه بيمارستاني به بيماركد 200اند. كد DRG 90 ، 450بيمار كد 50، 89بيمار 300و 410بيمار

كد . 475بيمار به كدها اين نسبي ارزش اند داده اختصاص خود به را. 9363، 134/5، 1447/1،/. 6990ترتيب اينگونه/. ميكس كيس باشد مي

: شود مي محاسبهCase mix = (200×6990/.)+(450×1447/1)+(300×134/5)+(50×9363/.)

1000

Case mix =2/24

Example . كنيد مقايسه را زير شرايط با بيمارستان دو دو .200هر اند كرده پذيرش را بيمار روزبيمار تعداد ، بيمارستان دو هر .1200در است بوده روز حدود بيماران اقامت .6متوسط است بوده روز . دقيق بررسي با اما است يكسان بيمارستان دو راندمان ظاهرا

با بيماران از نيمي الف بيمارستان در شود مي مشخص ترنسبي ارزش با ران كشاله فتق با 0.5تشخيص ديگر نيم و

نسبي ارزش با پيچيده معده زخم اند 1.0تشخيص شده بستري: شود مي محاسبه چنين ميكس كيس اين بنابر

Case mix = (100×./5+(100×1) = 150 ب بيمارستان با 100در پس باي جراحي تشخيص با بيمار

نسبي نسبي 100وبراي 5.5ارزش ارزش با كليه پيوند ديگر بيمار3.84 . مي محاسبه چنين ميكس كيس اين بنابر است شده انجامشود:

Case mix = (100×5/5+100×3/84)= 934 بيمارستان دهد مي نشان ها ميكس كيس مقايسه ترتيب اين به

تقريبا .9ب است كرده مصرف منابع از الف بيمارستان برابر

OPTIMIZATION AND CASE MIX Optimization may not be gained if the coder is

inexperienced in reading the medical record, understanding disease processes, unable to understand where to look for additional information such as drug usage, tests ordered, etc.  By providing the coder with ongoing education, this increases the chance that increased optimization.  Optimization may also not be possible due to lack or poor documentation and poor team relationships.   

Case mix is defined as the type of patients the hospital treats.  Facilities are very concerned on whether their patients are making them money or do they have a high percentage of patients in which it costs the facility more to treat the patient then what they are being reimbursed for.  

Case-Mix System is very appropriate especially in justifying the

usage of optimum resources in tertiary care hospitals which

admits more severe cases. At present, the allocation of

resources to hospitals are among others based on the number

of beds and previous resource utilization without considering

efficiency and thus did not contribute to the improvement of

hospital efficiency. Case-Mix System also facilitates in the

implementation of quality enhancement programm in line with it

original objective of classification. Information on patients’

treatment such as length of stay helps in identifying differences

in treatment and problems in quality of patient care so it can be

highlighted and managed immediately. Hospitals are also

encouraged to

standardize the treatment process using clinical guidelines and critical pathways in accordance to best practices to ensure that patients receive the best and most effective treatment. The Government of Malaysia has decided to introduce a national health care financing system to support the increasing health care cost and to enhance equity, accessibility, quality and efficiency in the health system. One of the element in financing is the health care provider payment mechanism based on this case-mix system. Therefore, HUKM has taken the initiative to lead the way in using case-mix system in this country and hope to extend its experience to other hospitals and insinuate its implementation to strengthen the health service in the country.

What Case Mix Is

Refers to the Mix of Cases of a Hospital, the Range and Type of Patients Treated

Case Mix Information can tell us How Much Money Hospitals Need According to the Patients they Actually Treat

Case Mix is Hospital Final Output, Classified into Predetermined Categories (DRGs)

Case Mix Information about Resource Use and Quality can be Used as Standards for Hospitals to Compare Based on patient characteristics

Case Mix is a Tool - Case Mix Information Provides the Knowledge to Critically Examine Patient Care and Manage Appropriately Comparative data

What Case Mix Is Not A Method for Cutting Health Budgets - Case Mix can Help Ensure that Available Funds are Distributed Rationally • A Tool to Control Doctors - Case Mix can be used to Compare the Kind of Treatment Doctors Give Patients • A Method of Changing Hospital Work Practices - Hospitals can use Information to Examine Practices and Identify Where Changes Might be Needed • A way of Removing Management of Health from Doctors and Nurses - Case Mix Enables Doctors and Nurses to Better Manage Health Care

CaseMix Analysis

The Ministry compares The Regions The Hospitals The Departments the Physicians... ...the Patients

NordDRG

The Nordic Medico-Statistical Committee

(NOMESCO) of the Nordic Council of Ministers

charged in 1995 the WHO Collaborating Centre for

the Classification of Diseases in the Nordic

countries with the task of designing a DRG

system, possible to use after the introduction of

ICD-10 and NCSP.

NordDRG

The objective of the design project was to create a

patient classification system that is public domain,

with openly accessible grouping definitions, based

on the ICD-10 and NCSP, and easily maintainable

and possible to develop beyond DRGs, in order to

meet the requirements of Nordic clinical practice.

The project was divided into three phases

1). Conversion tables between ICD-10 and ICD-9-CM and NSCP and ICD-9-CSP(classification of surgical procedures) , respectively, were produced and published Secondly, standardised HCFA-like DRG Definitions were created, directly using ICD-10 and NCSP codes Thirdly, grouping software was designed both as a “Common Nordic” version and as national versions, containing national modifications of the ICD-10 and NCSP The NordDRG Definitions and the NordDRG Grouper (national versions) are the property of the national health authorities. They are responsible for the national versions and their distribution within their respective country

NordDRG The Nordic Medico-Statistical Committee (NOMESCO) of the

Nordic Council of Ministers initiated in 1994 a project to create a Nordic case-mix system to make it possible to compare health care statistics in the Nordic countries. The case-mix system was also aimed for planning, budgeting, management and financing inpatient care at hospital.

The objective of the design project was to create a patient classification system that is public domain, with openly accessible grouping definitions, based on the ICD-10 and NCSP (Nomesco Classification of Surgical Procedures). The system has to be easily maintainable and possible to develop beyond DRGs, in order to meet the requirements of Nordic clinical practice. The system also had to derive from the logic in HCFA-DRG version 12.0.

In 1996 the first version of NordDRG was developed. From 1997 the new system was in practice in Stockholm County Council in Sweden and in some health care districts in Finland. In 2002 all Nordic countries use NordDRG except Island

Current condition Around 20 hospitals in Sweden have case-costing

systems for inpatient care in use (or 25% of the yearly cases in Sweden). The Federation of Swedish County Councils collects case-costing data from the hospitals to a national case-costing database.

The National case-costing project has been running since 1999. The project was ending in year 2002. Case-costing will continue as a part of the ordinary activity at the Federation of Swedish County Councils. Approximately 50% of the County Councils have local case-costing projects. This will hopefully lead to more cases in the case-costing database in the near future; many new hospitals are already implementing case-costing systems. Case-costing systems are today non-compulsory in Sweden.

Case-costing systems for psychiatry, outpatient care and primary care are also on the list for development. A few Swedish hospitals already implemented case costing for outpatient care

1980 The classification “Diagnosis Related Groups” (DRG) was established by Professor Robert Fetter and Jon Thompson from Yale University to categories patient scene in American hospital. The version that has been used contained 383-diagnosis group known as DRG, the first version using ICD-8 as “Grouping Principal System”. The second version contained 467 DRG group, which was created in line with ICD-9 and ICD-9-Cm for operation procedures.

1983 Health Care Financing Authority (HCFA) in USA used case-mix system to support the health services under social scheme insurance that is Medicare and Medicaid.

1990 Case mix system was introduced to Australia. The research over case-mix system has been resembled by the health services authority in South Australia, New South Wales University and the Royal Children’s Hospital in Melbourne. After that the case-mix system has been broaden to all places in Australia.

1992 Case-mix system was introduced in Singapore and has been tried as payment system in health service.

1994 Case-mix system was introduced in Thailand under the Thailand National Scheme insurance.

1997 The research on case-mix system as a method of health care financing in Malaysia was approved and given the budget under the IRPA Top-Down project to UKM, UM, USM and Ministry Of Health Malaysia.

TYPE OF CASE-MIX SYSTEM From the first version of DRG in 1983, some researcher have modified

the DRG for their used with changes made to satisfy the disease pattern in their country.

All Patient Refined DRGS (APR-DRGS) are using the patient sickness to ensure that the classification can only detected the patient that really needed the more resources causes by the chronic disease. Australia used their own Case-mix system that is Australia National DRGS (AN- DRG) since 1992. United Kingdom used Health Care Resources Group (HRG), and Canada used Classification Case-mix Group (CGM).

UKM hospital will be using the latest Case-mix system that is IR-DRG (International Refined DRG) that contains 965 groups .This system is fundamental to ICD-10 for main diagnosis and ICD-9CM for operation procedure. This IR-DRG classification will be a principle to achieve the establishment of Malaysia own Case-mix system in the future. The classification contains all group age and almost all-major operation that has been done in one hospital.

NordDRG weight list The DRG-weight is a relative measure of care and

treatment costs for an average patient in a DRG. A high weight indicates high cost. To get weight lists that are validated and representative the calculation must be based on a large database. The average cost for all cases in the database have the state of DRG-weight 1.0. The weight for each DRG is calculated by dividing the average cost for each DRG with cost that represents DRG-weight 1.0.

The DRG average cost is the basis for cost comparability in the calculation of cost-weights. Patients with a long length of stay or high cost may have a disproportional influence on the average cost. The method to exclude those cases from the database is called trimming and the excluded cases are representative

NordDRG weight list called outliers. About five percent of the database

are technical defined as outliers. Trimming the data is to improve the comparability of the data. When weight lists are used in a reimbursement system the outliers get paid separate. Limits for outliers are specified in the weight list.

Annually CPK produce a national weight lists based on the national case-costing database. All hospitals in the case-costing database have calculated the cost by the cost per case method.

The national weight lists are mainly used as a reference list. There is a predominance of region hospitals in the national case-costing database why the cost weights are not absolutely

Australia AN-DRG( Australian National DRG) اولين سيستمcommon we و 3M استراليا كه توسط DRGطبقه بندي

alth 1996 و 1992 بصورت مشترك ايجاد شد . بين ايجاد شده استand 3.1 3.0, 2.1, 2.0, 1.0نسخه هاي

AR-DRG دومين سيستم طبقه بندي DRG استراليا كه از در سالهاي 4.0 ، 3.2 ايجاد شده ونسخه هاي 1997سال

در سالهاي ICD-9-CM، 4.1 بر اساس كدهاي 1998-1991 از ICD-10-AM ، 4.2 بر اساس اولين ويرايش 2000-1998 ، تاكنون ICD-10-AM بر اساس دومين ويرايش 2001سال

استفاده شده اند. ساعات بيهوشي، تنفس مصنوعي و وضعيت بهداشت رواني از جمله مواردي است كه در اين سيستم در

-pre 8 به همراه MDC 23 از 4.2نظر گرفته شده اند. نسخه MDC 7 و error DRGs .تشكيل شده است MDC ها بر اساس

يك سيستم بدني واحد يا اتيولوژي كه به يك تخصص پزشكي خاص مربوط مي شود، ايجاد شده اند.

MBS: Australian Commonwealth Medical Benefit Schedule در پرداخت پزشكان استراليا استفاده مي شود.

Australia بندي گروه براي استفاده مورد :AR-DRGمتغيرهاي از عبارتند( ساير ( اصلي، ها تشخيصاقداماتجنسسن وقايع پايان [1]نوع اقامت مدت( موقت ( ترخيص بيمارستان ترك روزهاي( ) يكسال زير كودكان براي پذيرش هنگام وزنرواني وضعيت بهداشت مكانيكي تهويه [2]ساعات مي ترخيص روز همان در و پذيرش روز يك در بيمار كه هايي وضعيت

شود.

[1] Events end type [2] Hours of mechanical ventilation

AR-DRG V4.2:

Germany  G-DRG -  Diagnosis Related Groups

ICD-10 and OPS-301 Germany

The recent German Health Reform or “Gesundheitsreform

2000” will introduce a German Diagnosis Related Group

(G-DRG) system in the hospital sector planned to be fully

operational by 2003. Up to then run the adaptation time of

the German health system on DRG-System. This reform

will change the current hospital financing system on the

basics of Australian DRG-System. The Departments for

Psychiatry are excluded from DRG-financing.  Hospitals

are using ICD-10 Version 2.0 for Diagnosis-Coding and

OPS-301 for Procedure-Coding (12.06.2001)

canada ميكس كيس هاي گروه كانادا اساس )CMG(در بر

بيشترين ترخيص زمان در كه تشخيص، ترين معتبرشده ايجاد دهد، مي اختصاص خود به را اقامت طول

نياز. اساس بر مرتبا ميكس، كيس هاي گروه اند . و بيماري پيچيدگي مثال شوند مي روزآمد كاربران، . سن است شده لحاظ گروهها در اخيرا بيمار سنو سن كم بيماران كه است مهم جهت اين از بيمار

درماني تدابير به اغلب مسن و پير افراد و سال. دارند نياز بيشتري

America(case mix classifications)

Yale refinement DRGs : از وري بهره عوارض و همزمان هاي بيماري هاي پيامد مطالعة اساس بر

. مرتبط ثانويه هاي تشخيص همچنين است شده تنظيم بيمارستاني منابع. اند گرفته قرار توجه مورد اصلي هاي تشخيص برخي با

New York DRGs ولي شوند، نمي انتخاب مديكير توسط كه هايي فعاليت سازي يكپارچه

انجام مسن افراد براي ها فعاليت اين شوند مي انجام سايربيماران براي... . و دارويي اعتياد ، نوزادان هاي بيماري ها، جراحت ايدز، مثل شوند نمي New York CSI DRGs

 DRGs  :توسط پژوهشگران موسسة پزشكي نمايه شدت نيويورك DRG ايجاد شد و به شدت بيماري در 1980جانز هاپكينز در اوايل دهة

معيار شدت بندي شد: 4توجه شد.هر تشخيص اصلي يا ثانويه براساس و زير گرو ه هايي براي هر يك سبك، متوسط، شديد، تهديد كنندة زندگي

در نظر گرفته شد.

America(case mix classifications)

Pediatric Modified DRGs (PM-DRGs) سالهاي هاي 1984- 1987طي بيمارستان ملي انجمن توسط

مربوطه موسسات و از) NACHRI ([1]كودكان كمتر بيماران برايكه 17 بود اين سيستم اين ايجاد اصلي علت شد ايجاد DRGسال

در اغلب كه را كودكان پيچيده و پرهزينه هاي وضعيت ، اصلينمي منعكس خوبي به شدند مي درمان تخصصي هاي بيمارستان

مراقبت. به نياز كه كودكاني براي كافي منابع ارائه در بنابراين كردرا ها مراقبت اين كه هايي سازمان براي و داشتند خاص پزشكي

. منظور به ترتيب اين به شد مي ايجاد مشكالتي ، كردند مي ارائهصد حدود مشكالت اين افزوده DRGبه DRGرفع قبلي هاي

مكمل. سيستم اين واقع در .DRGشد آن از بخشي نه است

LTC-DRGs

long-term care diagnosis- related groups Cases are classified into LTC-DRGs for payment

based on the following six data elements: (1) Principal diagnosis. (2) Up to eight additional diagnoses. (3) Up to six procedures performed. (4) Age. (5) Sex. (6) Discharge status of the patient

England سال در ، انگلستان المللي 1984در بين كنفرانس اولين ،DRG

. انجمن كنفرانس اين در شد برگزار لندن شركت PCS/E [1]در بااز . 6نمايندگاني زمان آن از شد تشكيل غربي اروپاي كشور

استراليا و اروپايي مختلف كشورهاي در ساالنه كنفرانس تاكنون . در جديد مفاهيم كنفرانس بحث مورد موضوع است شده تشكيل

زمينه اين در نيز رايگاني فصلنامه و است ميكس كيس عرصه . از بيش با انجمن اين امروزه كند مي از 50منتشر مختلف كشور

. كنفرانس در دارد ارتباط دنيا سال PCS/Eسراسر در 1999كهادنس شد، [2]در كرد IAP-DRG[3]سيستم 3Mبرگزار معرفي را

جاي به كه دارد وجود نيز آن شده خالصه نسخه سطح 4كهمجموع CCسطح 3داراي در و .1046بوده دارد گروه

[1] Patient classification systems/Europe [2] Odense

[3] International All Patient Diagnosis Related Groups

FranceDRG به كشور اورده شد.1980 در دهة DRG در فرانسه HGP ]1[نام گرفت. با بهره گيري ازHGP از طريق ،

تحليل انحراف معيار ها، گام موثري در مديريت مالي برداشته شده است. اقتصاد دانان فرانسوي عالقمند بودند با استفاده از يك مرجع

، 1991خارجي از وضعيت نسبي بيمارستان ها آگاه شوند. از سال در زمينة پزشكي سازي سيستم اطالعاتي HGPراهنماي استفاده از

(MIS)]2[ ايجاد شد. هدف رسيدن به يك پرداخت آينده نگر نبود، بلكه پايش و تلفيق اختصاص يك بودجة سراسري به بيمارستان هاي عمومي

بود. پس از مذاكره ميان وزارت بهداشت و وزارت بودجة فرانسه، ميزان عمومي برآمد هاي خاص در سطح ملي مشخص شد. در سطح

. در تورممحلي، بودجة ساليانه برابر است با بودجة قبلي ضربدر ميزان اين اقدام مالي، ضرر و زيان ها و نوسانات احتمالي به علت سرمايه

گذاري هاي محلي و همچنين افزايش يا كاهش فعاليت بيمارستان ناديده گرفته مي شود

با مقايسه DRGدر . ، شدند،درحاليك اضافه ها گروه برخي است كرده تغيير ها گروه شمارة

ردة يك از ها تشخيص از تعدادي همچنين شدند، خارج سيستم از برخي هشدهاند. منتقل ديگر ردة به اصلي

[1] Homogeneous groups of patients [2]Medicalisation of the Information System

Other countries

Thailand

Taiwan

Indonesia

Denmark

Finland

Italy

Malaysia

Singapore

ايرانگرفته بکار پرداخت روش نوع اين ايران طبقه در نظام و شود مي

پرداخت روش بکارگيري جهت اساس و پايه عنوان به که اي بندي " نظام عنوان با نظامي شود مي استفاده . "گلوبالموردي در است

طبق بر بيماران نظام، شايع 60اين جراحي اعمال از طبقه مورد " . نظام گردند مي " گلوبالبندي هاي" گروه نظام با مقايسه در

. " نظام است بسياري نواقص داراي تشخيصي موارد "گلوبال" مرتبط ،در تنها و جراحي اعمال مورد در تنها و نشده شامل را 60بيماري

. اصلي، تشخيصي طبقات دارد کاربرد مرتبط مورد های گروه " بطور " تشخيصي مرتبط هاي گروه هاي نظام در که پايه تشخيصی

نظام در است شده گرفته نظر در کامل و وجود "گلوبال" جامعو. متناقض، و غيرمعتبر اطالعات جهت طبقاتي همچنين ندارد . سن، متغيرهاي است نشده گرفته نظر در بيمار ترخيص وضعيتخاص سطح همراه، هاي بيماري و عوارض وجود عدم يا وجود جنس،

و تولد عوارض زمان وزن همراه، هاي بيماري /

ايرانسطح يا و بيماري شدت و نداشته وجود نوزادان در پذيرش

و بيمار، کلينيکي به پيچيدگي توجه با توان نمي را خطرمرگ نيز " . مرتبط هاي گروه هاي نظام در نمود تعيين نظام اين

" " که" گيرد مي تعلق کدي ، گروه هر به طبقه تشخيصي کدهاي بانظام در اما است، هماهنگ و مرتبط ها بيماري المللي بين بندي

. "گلوبال" وزن عامل ديگر طرفي از شود نمي انجام کدگذاريبه توجه با بيمار هزينه محاسبه در که اي، هزينه وزن يا نسبي

" " گروه، هر جهت تشخيصي مرتبط های گروه طور نظام بهنظام در شود مي تعيين نشده "گلوبال" جداگانه گرفته درنظر

نظام. داشت اظهار توان مي ترتيب بدين در "گلوبال" است " و " ها کمبود داراي تشخيصي مرتبط های گروه نظام با مقايسه

است . نواقصي