Hospital Modernization Implementation/
APR DRG Workshop
Presented by
The Department of Social Services
& HP Enterprise Services
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Training Topics
• Hospital Modernization Overview
• Inpatient Payment Methodology
• Hospital Billing Changes – Interim Claims
• 3M APR DRG Assignment Tool
• DRG Pricing Calculator
• Transfer Claims
• Interim Claims
• Partial Eligibility Claims
• Outlier Claims
• Organ Acquisition Cost RCC 81X
• Claims Paid at Per Diem Rate
• Health Care Acquired Condition (HCAC) / Present on Admission (POA)
• Ungroupable Diagnosis Codes
• Remittance Advice / Health Care X12 835
• Explanation of Benefit (EOB) Codes
• Hospital Modernization Web Page
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Hospital Modernization Overview
The purpose of this workshop is to educate hospitals that, as
required by section 17b-239 of the Connecticut General
Statues, the Department of Social Services (DSS) is changing
inpatient hospital reimbursement for general acute care
hospitals and children’s hospitals from the current model of
interim per diem rates and case rate settlements to an APR
DRG system where hospital payments will be established
prospectively for inpatient stays with a date of admission on or
after January 1, 2015.
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Hospital Modernization Overview
• These changes do not apply to chronic disease hospitals,
psychiatric hospitals or free-standing birth centers.
• These changes do not apply to inpatient admissions prior to
January 1, 2015 even if the client is discharged after January 1,
2015. They will continue to processing using the current
methodology.
• APR DRG will apply to out-of-state and border hospitals
enrolled in the Connecticut Medical Assistance Program
(CMAP).
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Hospital Modernization Overview
• What is APR DRG?
–In general, every complete inpatient stay is assigned to a
single diagnosis related group (DRG) using a computerized
algorithm that takes into account the patient’s diagnoses,
age, procedures performed, and discharge status.
–Each DRG has a relative weight that reflects the typical
hospital resources needed to care for a patient in that DRG
relative to the hospital resources needed to take care of the
average patient.
• DSS has selected 3M's APR DRG methodology. HP will integrate
3M's grouper software into its interChange claims processing
system.
–Version 31 of APR DRGs will be implemented January 1,
2015. There are approximately 1,200 groups or APR DRG
values.
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Inpatient Payment Methodology
• Base DRG payment is calculated by [Hospital Base Rate *
DRG Weight].
• DRG Weight, Average Length of Stay (ALOS), and Outlier
Threshold for the DRG code will be located on the DRG pricing
calculator spreadsheet on a tab titled DRG Table CT. This will
be posted to the Web site www.ctdssmap.com on the Hospital
Modernization page under the “DRG Calculator”. The DRG
weight and ALOS are national standards. The outlier thresholds
were developed specifically for CT through the rate setting
process.
• Hospital Base Rate were sent to the hospitals separately.
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Inpatient Payment Methodology
• Hospital’s payment will not exceed the total amount billed on
inpatient claims with an admission or after January 1, 2015.
• Hospitals are not required to submit the DRG code on the
inpatient claim. The Connecticut Medical Assistance Program
(CMAP) claims processing system assigns the APR DRG to the
claim and calculates the payment.
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Hospital Billing Changes – Interim Claims
• Historically hospitals would submit interim claims for the
following reasons:
–If the inpatient stay overlaps the hospital’s fiscal period.
–If the inpatient stay overlaps a calendar year.
–If the inpatient stay overlaps a hospital rate change.

For inpatient claims that overlap a hospital rate change,
the inpatient claim will be priced based on the DRG rates
on file based on the date of discharge.
–If the client is only covered for part of the inpatient stay.
 The
hospital will be required to submit for the entire
admission with all charges and services related to the
admission.
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Hospital Billing Changes – Interim Claims
• For inpatient claims with an admission date prior to January 1,
2015, interim billing, sometimes referred to as split-bills or
interim claims, may continue to be billed.
• Effective with inpatient hospital admissions on or after January
1, 2015, interim claims can no longer be billed by the hospital,
with one exception.
–One interim claim may be billed when the actual length of
stay reaches 29 days.
–For example, if the hospital stay spanned 1/1/2015 –
2/25/2015, the hospital can bill one interim claim with a date
span of 1/1/15 – 1/29/15 (29 days) or greater with a patient
status 30 “Still a Patient” and Type of Bill (TOB) 112
“Inpatient – First Claim”.
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Hospital Billing Changes – Interim Claims
• Newly created Explanation of Benefit (EOB) codes have been
created to deny the following inpatient claims:
–EOB code 0674 “DRG Interim Claims not Allowed”
 If
an inpatient claim is submitted with a patient discharge
status of 30 “Still Patient”, indicating the patient is still in
the hospital, it will be denied with EOB code 674 “DRG
interim claims not allowed” if the number of days submitted
is less than 29 days for admission on or after January 1,
2015.
–EOB code 5075 “Only One Interim Claim Allowed Per Stay”
 If
a second interim bill is submitted and there is a paid
interim claim for the same admit date in history.
• Hospitals can adjust an interim claim, replacing it with an
extended interim claim.
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Hospital Billing Changes – Interim Claims
• Newly created Explanation of Benefit (EOB) codes have been
created to deny the following inpatient claims:
–EOB code 5076 “Paid Interim and Final Claim For Same
Admission Not Allowed”
 If
the final inpatient claim is submitted with an interim
claim still paid in history, the claim will be denied with EOB
code 5076.
• Once the client is discharged, the interim claim must be either
adjusted, or recouped and resubmitted, for the entire stay.
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DRG Pricing Calculator
• DRG Pricing Calculator – A calculator spreadsheet is available to
assist hospitals in calculating payment for a single inpatient
claim with the input of only a few data elements.
–Elements include, but are not limited to, the following: DRG
and Severity of Illness (SOI) code, hospital base rate,
hospital cost-to-charge ratio, and submitted charges.
–Hospitals might need to include additional information such
as; if the client was only eligible for part of an inpatient
admission or if the client was a transfer from one hospital to
another.
• The DRG pricing calculator is ready for use and has been posted
to the Hospital Modernization Web page under DRG Calculator.
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DRG Pricing Calculator
• The DRG Pricing Calculator includes the following tabs:
–Cover - The "Cover" worksheet contains an introduction to
the APR DRG Calculator and offers Web sites where
stakeholders can learn more about the Connecticut Medical
Assistance Program's (CMAP) inpatient APR DRG pricing
method.
–Structure - The "Structure" worksheet contains a synopsis of
the information provided in the DRG Calculator spreadsheet.
–Calculator Instructions - The "Calculator Instructions"
worksheet contains a description of the data that must be
entered to estimate the CMAP payment amount for an
inpatient hospital stay. The instructions also describe the
calculations being made to determine the payment amount.
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DRG Pricing Calculator
• The DRG Pricing Calculator includes the following tabs: cont.
–Interactive Calculator - The "Interactive Calculator"
worksheet is the primary worksheet in the APR DRG Pricing
Calculator spreadsheet. All other worksheets exist to support
the "Interactive Calculator”. The user can enter just a few
data elements describing an individual hospital admission at
the top of the "Interactive Calculator" and an estimate of the
CMAP payment for that admission will be displayed at the
bottom of the Calculator.
• One of the fields to enter in the interactive calculator is the APR
DRG code. Hospitals are not required to submit the APR DRG
code on their inpatient claims. However, we do offer a way for
the hospitals to identify the appropriate APR DRG code using 3M
Health Information Systems software.
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3M APR DRG Assignment Tool
• 3M Health Information Systems has made a tool available to the
hospitals to determine the APR DRG based on input of several
data elements.
–The tool is available on the Web site www.aprdrgassign.com.
 In
order to access this Web site, users will be required to
enter a User ID and Password. To obtain this User ID and
Password, please send a request via e-mail to
ctxixhosppay@hp.com.
• Once you receive the User ID and Password, you will need to
read the terms and conditions and enter the User ID and
Password to accept the agreement and log into the site.
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3M APR DRG Assignment Tool
• 3M Health Information Systems
• Click on the APR DRG Assignment Report.
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3M APR DRG Assignment Tool
• 3M Health Information Systems
• Click on APR Calculator.
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3M APR DRG Assignment Tool
• 3M Health Information Systems
–Data Entry Tab - Demographics
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3M APR DRG Assignment Tool
• 3M Health Information Systems
–Data Entry Tab - Demographics
1. Grouper Version – Select from drop down “APR DRG
Grouper” v31.0 (10/01/13) ICD-9
2. Grouping Type – There are two options for the grouping
type: Discharge DRG and Admission/Discharge DRG. The
grouping type determines if the report will include both
Admission and Discharge information, or just Discharge
information.
− Select: Admission/Discharge DRG (Excludes non-POA
(Present on Admission) Complication of Care codes).
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3M APR DRG Assignment Tool
• 3M Health Information Systems - Data Entry Tab -
Demographics
3. Case ID – User can enter any alphanumeric code to identify
their case.
4. Sex – Select Male, Female, or Unknown.
5. Discharge Status – Select the patient status on the claim
from the drop down selection.
6. Admission Age – Enter the age of the client at the time of
admission in days or years.
7. Admission Date and Discharge Date – Enter the date of
admission and discharge date of the inpatient stay.
8. Birth Weight Option – Select 7 “Entered or coded
w/default, X-chk”.
9. Birth Weight (Grams) – Enter weight of newborn in grams.
10. Days on Mech. Vent. – Leave Blank
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DRG Pricing Calculator
• 3M Health Information Systems - Data Entry Tab – Codes
– Diagnoses
• Enter the diagnosis on the claim beginning with the Principal
Diagnosis (PDX).
• Enter the corresponding Present on Admission (POA) indicator
for each diagnosis.
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3M APR DRG Assignment Tool
• 3M Health Information Systems - Data Entry Tab – Codes
– Procedures
• Enter all the procedure codes with their corresponding dates
from the inpatient claim.
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3M APR DRG Assignment Tool
• 3M Health Information Systems – Output Report
• Once all information has been entered, under the output report
tab, click on “Click here to see output report” to get the report
on your request which will include the APR DRG and SOI code
for the inpatient stay.
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3M APR DRG Assignment Tool
• Example 1 – Inpatient stay admitted on January 11, 2015 and
discharged on January 21, 2015 with a discharge status 01 for a
female client 34 years old.
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3M APR DRG Assignment Tool
• Example 1 – Enter Diagnosis and ICD Surgical Procedure codes.
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3M APR DRG Assignment Tool
• Example 1 – Output Report – Identifying DRG and SOI code as
139-3.
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DRG Pricing Calculator
• Interactive Calculator
• Each field is defined under the Calculator Instructions, but the
fields highlighted in green are required to be entered by the
user.
–Submitted Charges – UB-04 field locator 47.
–Non-covered Charges – UB-04 field locator 48. This would
include charges for non-covered days.
–Length of Stay – This is used in pricing transfer stays or
partial eligibility.
 The
length of stay equals discharge date minus admit date,
unless the discharge date equals the admit date, in which
case length of stay is 1.
Inpatient stay admitted on January 11, 2015 and
discharged on January 21, 2015, the hospital would enter
10.
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DRG Pricing Calculator
the stay is for a transfer claim, the length of stay will
equal discharge date minus admit date plus one day.
 If
Inpatient stay admitted on January 11, 2015 and
transferred on January 21, 2015, the hospital would enter
11.
–Client Eligible Days – Used for non-covered days
adjustments. Enter the number of days the client is eligible
during the stay, In most cases this will equal the full length of
stay including transfer claims.
–Was patient transferred with discharge status = 02 or
05? - Enter Yes or No from the drop down box.
–Organ Acquisition Costs – If billing RCC 81X, enter billed
amount.
–Practitioners Costs – If the hospital’s bills 96X, 97X, 98X on
the institutional claims instead of CMS-1500 the service will
be denied on the claim and the hospital needs to enter the
billed amount in this field.
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DRG Pricing Calculator
–Third Party Liability (TPL) – Enter TPL payment.
–Provider AVRS ID and Name – Fields are optional and do
not affect the DRG calculations.
–Hospital Base Rate – Enter the individual hospital’s base
rate.
•
Hospital Base Rates were sent to the hospitals separately.
–Hospital cost-to-charge ratio – Enter the individual
hospital’s cost-to-charge ratio which was included with the
hospital’s base rate from DSS.
• Once you entered all the information, the DRG pricing calculator
will estimate the APR DRG allowed amount (E45) and payment
amount (E48).
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DRG Pricing Calculator
• Example 1 – Inpatient stay admitted on January 11, 2015 and
discharged on January 21, 2015 with a discharge status 01 for a
female client 34 years old. Total charges $25,000, APR DRG
1393, APR DRG weight 0.9394, Average Length of Stay (ALOS)
of 4.51, and DRG Outlier Threshold of $30,251.98. The
Hospital base rate is $4,750.00 and Hospital cost-to-charge
ratio is 0.42826.
• APR DRG weight, ALOS and DRG Outlier Threshold amounts are
found under the DRG Table CT on the DRG Pricing Calculator.
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DRG Pricing Calculator
• DRG Table CT - The "DRG Table CT" is the final tab under the
DRG calculator that contains a list of the APR DRG codes and
parameters used in pricing individual hospital inpatient stays.
APR DRG codes, descriptions, national relative weights, and
Average Lengths of Stay (ALOS) are determined by 3M Health
Information Systems. The DRG Outlier Thresholds were
developed specifically for CT through a rate setting process.
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DRG Pricing Calculator
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DRG Pricing Calculator
• Payment amount is $4462.15.
• EOB code 8600 “Reimbursed via DRG Pricing” will post to
claims that pay at DRG pricing.
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DRG Pricing Calculator
• Example 2 – Inpatient stay admitted on January 28, 2015 and
discharged on January 30, 2015 with a discharge status 06 for a
female client 47 years old with a TPL payment of $300. Total
charges $16,491.77, APR DRG 1973, APR DRG weight 0.9773
with a DRS Outlier Threshold of $32,434.45. Hospital base rate
is $5,178.56 and Hospital cost-to-charge ratio is 0.28484.
• TPL amount needs to be entered on the interactive calculator to
calculate the correct payment amount.
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DRG Pricing Calculator
• Third Party Liability entered as $300.00.
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DRG Pricing Calculator
• APR DRG allowed amount was $5,061.01 minus TPL payment
$300.00, actual payment amount is $4,761.01.
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Transfer Claims
• Transfer claims are identified with a patient status 02
“Discharged/transferred to another short-term general hospital
for inpatient care” or 05 “Discharged/Transferred to a
Designated Cancer Center or Children's Hospital”. All other
transfer related discharge statuses are paid at the full DRG rate.
• If the claim is a transfer claim, the transferring hospital receives
a prorated payment based on the number of days on the claim
compared to the average length of stay for the assigned DRG.
–The Length of Stay (LOS) on the transferring hospital claim is
increased by one to reflect that a larger percent of the cost is
incurred on the first day of an inpatient stay.
• Transfer claim payment is based on a Prorated payment
calculated by the following formula not to exceed the pretransfer APR DRG base payment:
(Base DRG Payment /ALOS ) * (LOS +1)
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Inpatient Payment Methodology –
Transfer Claims
• If the transfer claim assigns DRG 580X or 581X, it will pay the
full DRG rate and will not be paid a transfer rate even if the
discharge value is a transfer value of 02 or 05.
• Transfer Claim – Example 1
−Inpatient stay admitted on January 6, 2015 and discharged
on January 9, 2015 with a patient status 02 for a male client
22 years old. Total charges $15,000 APR DRG 3512, APR DRG
weight 0.5584, ALOS 2.71 and a DRG Outlier Threshold as
$30,000. Hospital base rate is $5178.56 and Hospital cost-tocharge ratio is 0.28484.
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Transfer Claims
• Length of stay and client eligible days should be entered as 4
days (LOS +1). In the field “Was patient transferred with
discharge status = 02 or 05?” select “Yes” from the drop down.
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Transfer Claims
• Transfer base payment $4,268.21 is greater than APR DRG base
payment $2,891.71 so the payment amount will be $2,891.71.
• EOB code 8604 “Reimbursed with DRG Transfer Rate” will post
to transfer claims.
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Transfer Claims
• Transfer Claim – Example 2
−Inpatient stay admitted on January 12, 2015 and discharged
on January 14, 2015 with a patient status 02 for a male client
22 years old. Total charges $17,500, APR DRG 2803, APR
DRG weight 1.0089, ALOS 4.04, and a DRG Outlier Threshold
is $32,710.92. Hospital base rate is $5178.56 and Hospital
cost-to-charge ratio is 0.28484.
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Transfer Claims
• Length of stay entered as 3 days (LOS +1).
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Transfer Claims
• Transfer base payment is $3879.69 is less than APR DRG base
payment of $5,224.65 so the payment amount will be
$3,879.69.
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Interim Claims
• Interim claims are calculated based on the following formula:
Length of Stay (admission date to through date) * (Base DRG
payment/ALOS)
Payment example of an interim claim
• Inpatient claim with a date span of 1/1/2015 – 2/25/2015 and
the hospital chooses to bill for the first 30 days of the admission
as an interim bill.
The Base DRG payment of $37,961.85 and the Average Length
of Stay (ALOS) for DRG 6022 is 42.49.
Length of Stay (admission date to through date) * (Base DRG
payment/ALOS)
30 * ($37,961.85/42.49) =
30 * ($893.43) = $26,802.91
• The DRG pricing for the interim bill is $26,802.91.
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Interim Claims
• Average Length of Stay (ALOS) for DRG 6022 is 42.49
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Interim Claims
• Base DRG payment of $37,961.85
• Interim claims do not pay out using the DRG calculator, it is
based on the formula so in this example the payment amount
would be $26,802.91, not based on the calculator $37,961.85.
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Partial Eligibility Claims
• Partial Eligibility claims are calculated on a prorated
payment using the following formula:
–Base DRG Payment * [number of days eligible/LOS of claim
(through date – admit date)].
• Example of a Partial Eligible Inpatient Claim Payment
• Client is only eligible for 2 days out of a 4 day inpatient
admission.
Base DRG Payment for is $10,389.74 and the client was
admitted to the hospital on January 6, 2015 and discharged on
January 10, 2015, but only eligible from January 8, 2015 to
January 10, 2015 for 2 days.
$10,389.74 * (2/4) =
$10,389.74 * (.50) = $5,194.87
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Partial Eligibility Claims
• DOS (Admit – through) of claim is 1/6 – 1/10 – length of stay is
4. Eligibility is 1/8 – 1/10, client was eligible the night of the 8th
and the 9th, client eligible days are entered as 2.
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Partial Eligibility Claims
• The DRG pricing for the partially eligible claim is $5,625.92.
• EOB code 8605 “Reimbursed with Prorated Eligibility
Adjustment” will set to partial eligible claims that pay at a
prorated rate.
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Partial Eligibility Claims
• Example of a Partial Eligible Inpatient Claim Payment
• Client is only eligible for 2 days out of a 6 day inpatient
admission.
−Base DRG Payment for is $9,426.53 and the client was
admitted to the hospital on January 1, 2015 and discharged
on January 7, 2015, but only eligible from January 1, 2015 to
January 3, 2015 for 2 days.
$9,426.53 * (2/6) =
$9,426.53 * (.333333) = $3,142.17
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Partial Eligibility Claims
• DOS (Admit – through) of claim is 1/1 – 1/7 – length of stay is
6. Eligibility is 1/1 – 1/3, client was eligible the night of the 1st
and the 2nd, client eligible days are entered as 2.
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Partial Eligibility Claims
• The DRG pricing for the partially eligible claim is $2,946.25.
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Outlier Claims
• The Department recognizes that, due to the complexity of the
illness or other complicating conditions, there are stays that are
costly in relation to other stays within the same APR DRG
assignment. APR DRG methodology’s implementation includes
a provision to pay additional amounts for these cases that have
significant outliers where costs are far above those envisioned
in the development of the DRG rates.
• Outlier methodology will be based on a cost outlier threshold
established through a statistical formula based with a minimum
threshold per DRG.
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Outlier Claims
• Outlier Payments are calculated based on the following
formula:
−(Hospital Specific estimated cost of the stay – APR DRG base
payment) – DRG Outlier Threshold * 75% = Cost Outlier
Payment.
 Hospital
specific estimated cost of the stay is calculated
based on the following formula:
 Allowed Charges * Hospital Cost-to-Charge Ratio (were
sent to the hospitals separately) = Hospital specific
estimated cost of the stay.
Allowed charges = Total Charges (claim) – non-covered
charges (claim) – organ acquisition costs- practitioner costs.
• The Cost Outlier Payment will be added to the APR DRG base
payment to calculate the payment amount on the claim.
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Outlier Claims
• Allowed Charges $75,000 – $1,000 - $8,725 - $500 =
$64,775.00.
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Outlier Claims
• Allowed Charges $64,775.00 * Hospital cost-to-charge ratio
0.21484 = Hospital specific estimated cost of the stay
$13,916.26.
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Outlier Claims
• Example of an Outlier Payment • Inpatient stay admitted on January 9, 2015 and discharged on
February 25, 2015 with a patient status 01 for a female client
53 years old. Total charges $90,366.00, APR DRG 0422, APR
DRG weight 0.6838, ALOS 5.78, and a DRG Outlier Threshold as
$30,000 at an outlier percentage of 75%. Hospital base rate is
$5,772.93 and Hospital cost-to-charge ratio is 0.47008.
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Outlier Claims
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Outlier Claims
Cost Outlier Payment = [(Hospital Specific estimated cost of the
stay – APR DRG base payment) – DRG Outlier Threshold] * 75%
−Cost Outlier Payment =[($42,479.25 - $3,947.53) - $30,000] *
75%
−Cost Outlier Payment =($38,531.72 - $30,000) * 75%
−Cost Outlier payment =$8,531,72 * 75%
−Cost Outlier payment =$6,398.79 will be added to the payment
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Outlier Claims
• Cost Outlier Payment + APR DRG base payment = Payment
Amount.
–$6,398.79 + $3,947.53 = Payment Amount of $10,346.32.
• EOB code 8603 “DRG Outlier Amount Applied” will post to
claims that hit a DRG Outlier Threshold adjustment.
• Organ Acquisition Cost Revenue Center Code (RCC) 81X,
Practitioner Costs RCC 96X, 97X, 98X and non-covered charges
are excluded from calculation of outliers. If the hospital bills for
these services, they must enter it on the DRG calculator to
ensure the DRG calculator payment amount is correct.
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Outlier Claims
• Organ Acquisition Cost Revenue Center Code (RCC) 81X,
Practitioner Costs RCC 96X, 97X, 98X and non-covered charges
are excluded from calculation of outliers and should be entered
in the fields below on the DRG calculator.
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Organ Acquisition Cost RCC 81X
• Organ Acquisition costs (RCC 81X) will be reimbursed outside of
the APR DRG payment methodology effective with admissions
on or after January 1, 2015. Claims that contain organ
acquisition charges will be suspended to allow the claim to be
manually priced. Once finalized, these claims will contain both
a DRG payment and an organ acquisition payment and will
include EOB 6000 “Claim was Manually Priced or Denied for
Missing Information”.
• Prior authorization for the hospital stay covers the authorization
for the organ acquisition cost.
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Claims Paid at Per Diem Rate
• APR DRG payment will be applied to all inpatient claims from
acute care hospitals except the following:
–Inpatient Behavioral Health Claims DRG range 740 – 776
–Inpatient Rehabilitation Claims DRG 860
• The DRG calculator should not be used to price claims that are
exempt from the inpatient payment methodology.
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Claims Paid at Per Diem Rate
• The following EOB codes will post to claims paying at per diem
rate:
–EOB code 8606 “Reimbursed via General BH Pricing” will
post to inpatient behavioral health claims DRG range 740 –
776.
–EOB code 8607 “Reimbursed via Rehab Pricing” will post to
inpatient rehab claims DRG 860.
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Health Care Acquired Condition (HCAC) /
Present on Admission (POA)
• Health Care Acquired Condition (HCAC) is an undesirable
situation, or condition that affects a patient, that arose during a
stay in a hospital or medical facility.
• The Patient Protection and Affordable Care Act (PPACA) requires
that states not pay for provider preventable conditions including
health care acquired conditions (HCACs) and other providerpreventable conditions (OPPCs).
• Providers currently report health care acquired conditions using
Present on Admission (POA) indicators on inpatient claims.
However, they are only validated for presence and validity.
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Health Care Acquired Condition (HCAC) /
Present on Admission (POA)
• Present on Admission Indicator
– Y - Diagnosis was present at the time of inpatient admission.
– N - Diagnosis was not present at the time of inpatient
admission.
– U - Documentation insufficient to determine if the condition
was present at the time of inpatient admission.
– W - Clinically undetermined. Provider unable to clinically
determine whether the condition was present at the time of
inpatient admission.
– Blank - As long as the corresponding diagnosis is on the POA
exempt list.
http://www.cms.gov/HospitalAcqCond/Downloads/POA_Exem
pt_Diagnosis_Codes.zip
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Health Care Acquired Condition (HCAC) /
Present on Admission (POA)
• HCAC is identified by POA indicator = N (Diagnosis was not
present at the time of inpatient admission) or U (Documentation
insufficient to determine if condition was present at the time of
inpatient admission).
• The implementation of DRGs for inpatient admissions on or
after January 1, 2015 will enable Connecticut to change the
administration of how claims with a HCAC are reimbursed.
• While the OPPC and HCAC portion of this policy was previously
handled through the cost settlement process, going forward,
this policy will be administered in claims processing.
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Health Care Acquired Condition (HCAC) /
Present on Admission (POA)
• For inpatient claims with dates of admission 1/1/2015 and after,
hospitals will not receive the higher DRG payment for cases
when one of the selected conditions (see table 1 and 2) is
acquired during hospitalization (i.e., was not present on
admission).
• EOB 8601 “Claim Contained HCAC - Priced at a Lower Rate”
will post to a claim if the HCAC code caused the claim to pay at
a lower rate
• EOB 8602 “Claim Contained HCAC – No Impact to Pricing” will
post to claims that include a HCAC code and had no impact to
pricing.
CT interChange MMIS
68
Health Care Acquired Condition (HCAC) /
Present on Admission (POA)
• Table 1 and 2 can be viewed on the Hospital Modernization Web
page under the Health Care Acquired Condition (HCAC) /
Present on Admission (POA) link.
• Table 1 is a list of diagnosis codes that will impact the DRG
payment when the POA indicator is either “N” or “U”.
• Table 2 is a list of both diagnosis and surgical procedure codes
that when billed on the claim with a POA indicator of “N” or “U”
will impact the DRG payment.
CT interChange MMIS
69
Ungroupable Diagnosis Codes
• Effective with dates of admission on or after January 1, 2015,
diagnosis codes identified by ICD-9-CM to “Use Additional
Digits” will no longer be accepted as valid diagnosis codes on an
inpatient claim. These diagnosis codes are considered
ungroupable in 3M's grouper software.
• As an example, diagnosis code 250 Diabetes Mellitus requires
the use of additional digits. If a claim is submitted with this
diagnosis code, the claim will deny with a newly created EOB
code.
CT interChange MMIS
70
Ungroupable Diagnosis Codes
• If a claim is submitted with one of these diagnosis codes, the
claim will be assigned DRG code 955 and deny with a newly
created EOB code 0690 “Principal Diagnosis Invalid as
Discharge”.
• If the inpatient claim returns with DRG 956 “Ungroupable”, it
means the DRG could not be determined based on the
information on the inpatient claim.
–The inpatient claim will deny with EOB code 0691 “DRG 956
– Ungroupable”.
• Additional EOB codes 0920-0927 will deny the claim if invalid
information is submitted on the claim and a DRG code cannot
be returned.
CT interChange MMIS
71
Ungroupable DRG Codes
• If the inpatient claim returns with DRG 956 “Ungroupable”, it
means the DRG could not be determined based on the
information on the inpatient claim.
• The inpatient claim will deny with EOB code 0691 “DRG 956 –
Ungroupable”.
• Additional EOB codes 0920-0927 will deny the claim if invalid
information is submitted on the claim and a DRG code cannot
be returned.
CT interChange MMIS
72
Remittance Advice and ASC X12N 835
• The DRG and severity code will be added to the hospital’s
Remittance Advice (RA) in 2015.
• DRG and SOI code – DRG 197 and SOI 3.
• EOB code 8600 “Reimbursed via DRG Pricing”.
CT interChange MMIS
73
Remittance Advice and ASC X12N 835
• An updated copy of the new RA will be posted to Provider
Manual Chapter 5 “Claim Submission Information”.
• The ASC X12N 835 Health Care Claim Payment/Advice, which is
an electronic RA will be updated to include additional DRG
related fields. Once the new fields are confirmed, the Hospital
FAQs will be updated.
CT interChange MMIS
74
Explanation of Benefit (EOB) Codes
• A full list of new EOBs codes once finalized and approved will be
posted to Provider Manual Chapter 12 “Claim Resolution Guide”.
The provider manuals can be downloaded by going to the
www.ctdssmap.com Web site. Go to Information, click on
Publications and scroll down to Provider Manual Chapter 12
“Claim Resolution Guide”.
CT interChange MMIS
75
Hospital Modernization Web Page
• Where to go for more information: www.ctdssmap.com
• Hospital Modernization Web Page
–The Web page includes Quick links, DRG Provider
Publications, Hospital FAQs, Hospital Important Messages,
DRG Calculator, Provider Manual updates, Provider
Training, and Contact Information.
CT interChange MMIS
76
Hospital Modernization Web Page
CT interChange MMIS
77
Hospital Modernization Web Page
CT interChange MMIS
78
Training Session Wrap Up
• Where to go for more information: www.ctdssmap.com
–Provider Bulletins
•
2014-79 IP Hospital Payment Modernization/APR DRG
• DSS Reimbursement Home Page
http://www.ct.gov/dss/cwp/view.asp?a=4598&q=538256
• HP has also made available an email address,
ctxixhosppay@hp.com, that can be used to submit questions
related to APR DRG reimbursement.
• Provider Manual Chapter 7 Update – To access the updated
provider manual go to “Publications,” then scroll to “Provider
Manual Chapter 7,” and then choose “Hospital Inpatient:
New Requirements Eff. 1-1-15” from the drop down
menu.
CT interChange MMIS
79
Training Session Wrap Up
• HP Provider Assistance Center (PAC): Monday through
Friday, 8 a.m. to 5 p.m. (EST), excluding holidays:
–1-800-842-8440
–1-800-688-0503 (EDI Help Desk)
CT interChange MMIS
80
Time for Questions
• Questions & Answers
CT interChange MMIS
81