DRG Optimization Workshop
Planning Notes
Planning Notes for DRG Optimization Workshop
Title: DRG Optimization Workshop
Objective: To provide an in-depth, analytic approach to the process of enhancing
inpatient reimbursement through better DRG Coding including an overall understanding
of the DRG system, its development and utilization. Various severity refined DRGs
along with update material for 2002 HCFA-DRGs, 2002 ICD-9-CM changes, APCs,
ICD-10-CM and current HCFA compliance efforts will be reviewed.
Upon Completion the Participants Will:
1. Understand the overall development and refinement of the DRG Payment System
as it is used by HCFA.
2. Appreciate the DRG Grouping Logic and how it affects inpatient reimbursement.
3. Understand the necessity for correct ICD-9-CM Coding (diagnoses and
procedures) for proper reimbursement under DRGs.
4. Have reviewed the 2001 update for both the HCFA-DRG System and the new and
changed ICD-9-CM codes.
5. Be able to delineate the systematic steps in assessing and addressing DRG
assignment.
6. Understand the importance of proper DRG assignment and the optimization
process for reimbursement under the DRG system.
7. Have knowledge of computer groupers and optimizers and their utilization.
8. Understand and appreciate the knowledge, background and capabilities of
personnel coding for and optimizing reimbursement under DRGs.
9. Appreciate the differences between 'concurrent' coding and 'after-the-fact' coding
for DRG assignment.
10. Appreciate the current compliance efforts in the DRG area currently underway by
the OIG, DOJ and HCFA.
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DRG Optimization Workshop
Planning Notes
11. Have reviewed the interface of the DRG payment system to the outpatient
payment reform in the form of APCs (Ambulatory Payment Classifications).
12. Appreciate the research being performed relative to systems such as AP-DRGs
and APR-DRGs, and other severity refined DRGs.
13. Understand the changes that will be made in transitioning to ICD-10-PCS and ICD10-CM.
14. Be able to relate the DRG process to areas such as UR, QA, physician
documentation and cost accounting.
15. Have knowledge of the future changes that are anticipated for the DRG system.
Audience: Hospital coders, medical records personnel, data processing support
personnel, business office personnel, insurance clerks, nursing supervisors, nurses as
appropriate, and administrative staff as appropriate.
Method of Presentation: The primary method is Lecture-Recitation with the use of
case studies. Interaction and questions from the audience are HIGHLY encouraged.
Exercises in the form of coding scenarios will be used.
Course Materials: Extensive Class Notes (including copies of Overhead
Transparencies). Class Notes will include copies of selected readings and special
materials as appropriate.
Student Materials: ICD-9-CM Manuals. DRG Assignment Manuals (if available).
Laptop computer DRG Groupers and/or Optimizers are welcome.
Course Times: 9:00 a.m. to 12:00 p.m., 1:00 p.m. to 4:00 p.m.
Outline:
I. Introduction
A. The DRG System
B. Historical Development and Utilization
C. The Future of the DRG System
1. SR-DRGs
2. AP-DRGs
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Planning Notes
3. APR-DRGs
D. DRGs and APCs
E. ICD-10-PCS and ICD-10-CM
II. DRG Assignment Process
A. Use of ICD-9-CM Coding
1. Diagnoses
2. Procedures
B. Use of Groupers
C. Related DRGs
D. Medical Record Reviews
E. Complications & Comorbidities
F. Special Parameters
1. Relative Weight
2. GMLOS
3. Outlier Threshold
G. Special Resources
1. Computer Optimizers
2. Reference Optimizers
III. Reimbursement Process Under DRGs
A. Systematic Process
B. Calculation Examples
C. Differences In Payment For Better DRGs
D. Case-Mix Index Considerations
IV. 2002 Update
A. New/Changed ICD-9-CM Codes
B. 2002 DRG Update
1. Payment Rates
2. New Rules/Regulations
3. Transfer Situation
V. Compliance And Overcoding For DRGs
A. Determination Of Principal Diagnosis
B. Upcoding and Monitoring
C. Justifying Secondary CCs
D. 72-Hour Pre-Admission Rule
E. HCFA As Secondary Payer
VI. DRGs and APCs
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DRG Optimization Workshop
Planning Notes
A. Overview of APCs
B. Commonality of DRGs and APCs
C. Payment System Interface
VII. DRG Optimization Case Studies (Selected Areas)
A. Nervous System
B. Ear, Nose, Mouth & Throat
C. Respiratory System
D. Circulatory System
E. Digestive System
F. Musculoskeletal System
G. Endocrine System
H. Neoplasms
IX. Severity Refined And Modified DRG Systems
A. Introduction
1. Refinement Processes
2. 'Severity' Versus 'Mortality' Concerns
A. HCFA's SR-DRGs
1. Special Report
2. Important Features
B. New York's AP-DRGs
1. Pediatric Modified DRGs
2. Key Features
C. 3M's APR-DRGs
1. Development
2. Key Features
D. Optimizing Reimbursement Under The 'New' Systems
X. Physician Involvement in DRG Coding
A. After-The-Fact Coding
B. Concurrent Coding
C. Interacting With Physicians
D. Pros & Cons For Different Approaches
XI. DRGs And Related Areas
A. Utilization Review/Quality Assurance
B. Cost Reporting Process
C. Medical Records
D. PRO Review
E. Cost Accounting & Internal Studies
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DRG Optimization Workshop
Planning Notes
XII. DRGs and The Future
A. ICD-10-PCS
B. ICD-10-CM
B. "H-Codes"
Notes: 1. This is an intensive one-day workshop emphasizing practical applications.
2. Questions submitted prior to the class are encouraged!
3. Reference materials, including actual cases, will be made available to class
participants as a part of their notes.
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