DRG DRG Grouping Algorithm

1
????????? DRG( DRG Grouping Algorithm )
2
DRG
(Diagnosis Related Groups) ????????????????????
?????????????????????????????????
???????????????????????????????????????????????
??????????????????? ??????????????????????
3
DRG
1. ???????? 25 MDC (MDC 1 - 25)
??????????? MDC 1 Nervous System MDC 2 Eye
2. ????? MDC ???????? DRG ?????
MDC Major Diagnostic Category
4
DRG
DRG ?? MDC ???????? ???????? 2 ??? - Surgical
??????????? (?????? OR) - Medical
??????????????
??? DRG ????????? MDC ?? - PreMDC -
Unrelated, Ungroupable, Invalid PDx
5
DRG
All Patients
Pre MDC, MDC 1 ... MDC 25
DRG 1 DRG 511 ( 499 DRGs)
6
PDx SDx, Proc Age, Sex, D/C Type
GROUPER
DRG
7
PDx Principal Diagnosis ???????
????????????????? ?? 1 diagnosis ????????
SDx Secondary Diagnosis ???????? (???
active) ???? ???????
???????????? ????? 0 diagnosis ???????????
8
Proc Procedures ?????????/??????? ????? 0
procedure ???????????
- Operating Room Procedures - Non-operating Room
Procedures - Procedure Combinations
9
Age 0 - 124Sex 1 male, 2 female
Discharge Type 1 with approval 4
transfer 2 against advice 5 other 3
escape 9 dead
10
PDx,SDx, Proc,Age, Sex, D/C Type
MDC DC DRG
1
2
DRG
11
Grouper Algorithm (HCFA v. 17)
Pre MDC Proc
MDC 24 PDx SDx
MDC 25 PDx SDx
MDC 1 - 23 PDx
12
Pre MDC
All Patients
Yes
Trach. w PDx exc. FMN Dx
483
No
Yes
Liver Transplant
480
No
Yes
Lung Transplant
495
No
BM Transplant
Yes
481
No
Yes
482
Trach. w PDx FMN Dx
No
Yes
482
Laryngectomy
No
A
( P 1,3 )
13
CASE 1
??? ???? 35 ?????????????? (K746) ?????????.????
20 ??? ??????????????? ?? Liver Transplantation
(5059)
MDC ?
14
CASE 1
PDx K746 SDx - Proc 5059 Age 35
Sex 1
Proc 5059 gt Pre MDC
15
Grouper Algorithm (HCFA v. 17)
Pre MDC Proc
MDC 24 PDx SDx
MDC 25 PDx SDx
MDC 1 - 23 PDx
16
MDC 24
A
1. PDx Trauma Dx 2. gt 2 Diff. Sign. Sites 3.
gt 3 Trauma Dx
Yes
MDC 24
No
B
( P 279, 280-288)
17
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 ?
18
CASE 2
PDx S0620 SDx S0200, S0210, S729 Proc - Age
28 Sex 1 D/C Type 8
No Proc gt Not Pre MDC
19
CASE 2
PDx S0620 SDx S0200, S0210, S729 Proc - Age
28 Sex 1 D/C Type 8
PDx Trauma gt MDC 24 ?
20
CASE 2
PDx S0620 SDx S0200, S0210, S729 Proc - Age
28 Sex 1 D/C Type 8
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
21
Grouper Algorithm (HCFA v. 17)
Pre MDC Proc
MDC 24 PDx SDx
MDC 25 PDx SDx
MDC 1 - 23 PDx
22
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
( P 303,304,305-309 )
23
CASE 3
???????? 29 ?? ???????????????????.
?????? ????????????? ????? ?? ????? ??????.
10 ??? ????????????????????????? ????????
PDx HIV disease result in Pneumocystis
carinii pneumonia (B206) SDx Oral candidiasis
(B370) Proc none
MDC ?
24
CASE 3
PDx B206 SDx Oral candidiasis (B370) Proc
- Age 29 Sex 2 D/C Type 1
No Proc gt Not Pre MDC
25
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
26
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
27
Grouper Algorithm (HCFA v. 17)
Pre MDC Proc
MDC 24 PDx SDx
MDC 25 PDx SDx
MDC 1 - 23 PDx
28
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 ?
29
CASE 4
PDx S064 SDx S0200, S0210 Proc 0124 Age
18 Sex 1 D/c Type 1
Proc 0124 gt Not Pre MDC
30
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 ?
31
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
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
( Index Table 2 P 44 )
33
??????????????????? 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 ??????????????
34
????? 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 (
???????????????????????????)
35
MDC gt DRG
1. ????? Diagram ???????? MDC Diagram
???????????????????? 2. ??? Proc / PDx ?? DC
???????? ?????? Assignment... 3. DC gt DRG
36
DC (Disease Cluster)
?????????/???????????????????????????
ICD-10
MDC 2
MDC 3
MDC 1
MDC...
Dx
DC9
DC10
DC12
DC...
Proc
DC1
DC4
DC5
DC...
37
????? DC
1. Diagram ????? ????????????? - ???????? Proc
ICD-9-CM Assign. - ???????? PDx ICD-10
Assign. 2. Surgical Heirachy (App. D) 3.
Unrelated OR Procedures (App. B) 4. Procedure
Combinations (App. C)
38
DCgtDRG
?? 2 ??? 1. ??????? - DRG DC - Age /or
CC 2. ?????????? AX, D/C Type
39
DCgtDRG
1. Diagram ?????????? 2. ??????????? - DRG
Definitions - DC, AX Def. (App. A)
40
CC
(Complications or Comorbidities)
Appendix F ??????????
1. Dx Defined as CC (CC List)
???????????????????? ??????????? 2. Exclusion
List ??????????? ??? CC List
???? CC ?? Exclusion List ?????????
( P 351-406 )
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
PDx K746 SDx - Proc 5059 Age 35
Sex 1
Proc 5059 gt Pre MDC
44
CASE 1
PDx K746 SDx - Proc 5059 Age 35
Sex 1
Proc 5059 gt Pre MDC
Proc 5059 gt DC 480 (Liver transplant)
45
CASE 1
PDx K746 SDx - Proc 5059 Age 35
Sex 1
Proc 5059 gt Pre MDC
Proc 5059 gt DC 480 (Liver transplant)
gt DRG 480
46
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 ?
47
CASE 2
PDx S0620 SDx S0200, S0210, S729 Proc - Age
28 Sex 1 D/C Type 8
PDx Trauma gt MDC 24 ?
48
CASE 2
PDx S0620 SDx S0200, S0210, S729 Proc - Age
28 Sex 1 D/C Type 8
PDx Trauma gt MDC 24 ?
S0620 gt Site 1, S0200 gt Site 0 S0210 gt Site
0, S729 gt Site 8 gt MDC 24
49
CASE 2
PDx S0620 SDx S0200, S0210, S729 Proc - Age
28 Sex 1 D/C Type 8
PDx Trauma gt MDC 24 ?
S0620 gt Site 1, S0200 gt Site 0 S0210 gt Site
0, S729 gt Site 8 gt MDC 24
No OR Proc gt DRG 487
50
CASE 3
???????? 29 ?? ???????????????????.
?????? ????????????? ????? ?? ????? ??????.
10 ??? ????????????????????????? ????????
PDx HIV disease result in Pneumocystis
carinii pneumonia (B206) SDx Oral candidiasis
(B370) Proc none
DRG ?
51
CASE 3
PDx B206 SDx B370 Proc - Age 29
Sex 2 D/C Type 1
PDx B206 gt MDC 25
52
CASE 3
PDx B206 SDx B370 Proc - Age 29
Sex 2 D/C Type 1
PDx B206 gt MDC 25
No Extensive OR Proc
PDx, SDx
53
CASE 3
PDx B206 SDx B370 Proc - Age 29
Sex 2 D/C Type 1
PDx B206 gt MDC 25
No Extensive OR Proc
PDx, SDx
PDx B206 gt AX489x
gt DRG 489
SDx B370 gt AX 489x
54
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 ?
55
CASE 4
PDx S064 SDx S0200, S0210 Proc 0124 Age
18 Sex 1 D/c Type 1
PDx Trauma gt MDC 24 ?
56
CASE 4
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
57
CASE 4
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
58
CASE 4
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
MDC 1 Proc 0124 DC 1
59
CASE 4
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
MDC 1 Proc 0124 DC 1
DC 1 Age gt 17, PDx in AX 2 gt DRG 2
60
CASE 5
PDx H259 SDx E118 Proc
1341 Age 70 Sex M D/C
Type 1
61
CASE 5
PDx H259 SDx E118 Proc
1341 Age 70 Sex M D/C
Type 1
Proc 1341 gt Not Pre MDC
62
CASE 5
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
63
CASE 5
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
MDC 2 Proc 1341 gt DC 39
64
CASE 5
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
MDC 2 Proc 1341 gt DC 39
DC 39 gt DRG 39
65
CASE 6
PDx J13 SDx E102 Proc
- Age 22 Sex F D/C Type
1
PDx Trauma Dx ? HIV/HIV Related ?
PDx J13 gt MDC ? DC ?
SDx E102 gt CC ?
DRG ?
66
CASE 6
PDx J13 SDx E102 Proc
- Age 22 Sex F D/C Type
1
PDx Trauma Dx ? HIV/HIV Related ?
PDx J13 gt MDC ? DC ?
SDx E102 gt CC ?
DRG ?
DRG 89
67
?????? CC
1. ?? SDx ??????????????? CC List ??????? ??????
gt ??????? CC 2. ??????? -gt ????? PDx ??????
Exclusion List ??????? ??????? gt ???????
CC ?????????? gt ???? CC 3. ????????????? CC
???????????? SDx
68
CASE 7
PDx J13 SDx E119 Proc
- Age 45 Sex M D/C Type
1
PDx Trauma Dx ? HIV/HIV Related ?
PDx J13 gt MDC ? DC ?
SDx E119 gt CC ?
DRG ?
69
CASE 7
PDx J13 SDx E119 Proc
- Age 45 Sex M D/C Type
1
PDx Trauma Dx ? HIV/HIV Related ?
PDx J13 gt MDC ? DC ?
SDx E119 gt CC ?
DRG ?
DRG 90
70
CASE 8
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
DRG ?
71
CASE 8
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 I019 gt MDC 5 DC 144
SDx I052 gt CC ?
72
CASE 8
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 I019 gt MDC 5 DC 144
SDx I052 gt CC ?
gt Yes
PDX CC Exc ?
73
CASE 8
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 I019 gt MDC 5 DC 144
SDx I052 gt CC ?
gt Yes
Yes gt Not CC
PDX CC Exc ?
74
CASE 8
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 I019 gt MDC 5 DC 144
SDx I052 gt CC ?
gt Yes
Yes gt No CC
PDX CC Exc ?
Yes gt Not CC
SDx E119 gt CC ? gt No
75
CASE 8
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 I019 gt MDC 5 DC 144
SDx I052 gt CC ?
gt Yes
Yes gt No CC
PDX CC Exc ?
SDx E119 gt CC ? gt No
DC 144 wo CC gt DRG 145
76
CASE 9
PDx K565 (Int. Adhesion w Obs)
SDx - Proc 5459,4709,4562 Age 32
Sex M D/C Type 1
DRG ?
77
CASE 9
PDx K565 (Int. Adhesion w Obs)
SDx - Proc 5459,4709,4562 Age 32
Sex M D/C Type 1
PDx K565 gt MDC 6
78
CASE 9
PDx K565 (Int. Adhesion w Obs)
SDx - Proc 5459,4709,4562 Age 32
Sex M D/C Type 1
PDx K565 gt MDC 6
Proc 5459 gt DC 150 4709 gt DC 166 4562
gt DC 148
79
CASE 9
PDx K565 (Int. Adhesion w Obs)
SDx - Proc 5459,4709,4562 Age 32
Sex M D/C Type 1
PDx K565 gt MDC 6
SH 4.0 5.0 2.0
Proc 5459 gt DC 150 4709 gt DC 166 4562
gt DC 148
80
CASE 9
PDx K565 (Int. Adhesion w Obs)
SDx - Proc 5459,4709,4562 Age 32
Sex M D/C Type 1
PDx K565 gt MDC 6
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
81
CASE 10
PDx R040 SDx I10 Proc
6069 Age 65 Sex M D/C Type
1
DRG ?
82
CASE 10
PDx R040 SDx I10 Proc
6069 Age 65 Sex M D/C Type
1
PDx R040 gt MDC 3
83
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
84
CASE 10
PDx R040 SDx I10 Proc
6069 Age 65 Sex M D/C Type
1
PDx R040 gt MDC 3
Proc 6069 gt Not in MDC 3 gt Unrelated
85
CASE 10
PDx R040 SDx I10 Proc
6069 Age 65 Sex M D/C Type
1
PDx R040 gt MDC 3
Proc 6069 gt Not in MDC 3 gt Unrelated
App. B 6069 gt DC 476
Only DC 476 gt Not 468
86
CASE 10
PDx R040 SDx I10 Proc
6069 Age 65 Sex M D/C Type
1
PDx R040 gt MDC 3
Proc 6069 gt Not in MDC 3 gt Unrelated
App. B 6069 gt DC 476
Only DC 476 gt Not 468
gt DRG 476
87
CASE 11
PDx N393 SDx N301 Proc
- Age 48 Sex D/C Type
DRG ?
88
CASE 11
PDx N393 SDx N301 Proc
- Age 48 Sex D/C Type
PDx N393 gt M MDC 11 F MDC 13
89
CASE 11
PDx N393 SDx N301 Proc
- Age 48 Sex D/C Type
PDx N393 gt M MDC 11 F MDC 13
Need Sex Data BUT No Sex Data
DRG 470
90
CASE X
PDx SDx Proc Age 25
Sex F D/C Type 1
91
Thai DRG Grouper Version 2.01

• FILES

• - CT2MSCC.DBF
• - CT2PCOM.DBF
• - CT2RW.DBF
• - CT2SH.DBF
• 3. VFP supporting library setup files
• 4. Icon file FLGTHAI.ICO
• 5. Data file

1. Grouper TGRP.EXE 2. DRG Grouper Library -
AL2DC.DBF - CT2AX.DBF - CT2CCEXC.DBF -
CT2ICD10.DBF - CT2PROC.DBF - CT2MDCPR.DBF
92
DATA FILE

• ?????????? .dbf ?????? Visual Foxpro
• ???????? fields ????? ???? ???? ???? ??????
• Age C,3
• Sex C,1
• Discht C,1
• PDx C,5
• SDx1 ... SDx12 C,5
• Proc1 ... Proc12 C,5
• Fields ???????? ????? ?????????????????
• RW N,74 OT N,62 WTLOS N,62

• DRG C,3 (????????? DRG ??????)
• MDC C,2 (????????? MDC ??????)
• Err N,2 (0 No error)
• Warn N,2 (0 No warning message)
• Result C,1

93
Error Codes

• Error ????????????????? ??????? DRG ??????
• Grouper ????????? DRG 470
• Error Codes
• 1 ????? PDx
• 2 ???? PDx ??? ( ??????? library files)
• 4 ????? AGE ????????????
• 8 ????? DISCHARGE TYPE ????????????
• 16 ????? SEX Data ????????????

94
Warning Codes

• ??????????????????????
• ????????????????????
• ??????????? DRG ???
• Warning Codes
• 1 Invalid or Duplicated SDx
• 2 Invalid or Duplicated Procedure
• 4 No or Invalid Age
• 8 No or Invalid Discharge Type
• 16 No or Invalid Sex
• 32 PDx with Site Code not in Library
• ( Warning code ?????????????? warning ???????)