Carondelet Health Network APR DRG Information for Physicians - PowerPoint PPT Presentation

Carondelet Health Network APR DRG Information for Physicians September 2014

Introduction Changes in the reimbursement process for services rendered to AHCCCS patients will go into effect beginning on October 1, 2014. The changes will impact reimbursement for inpatient services in the following facilities: • Short Term Acute Care hospitals • Critical Access hospitals • Inpatient Rehabilitation Services The up-coming changes do not apply to: • Free-standing rehabilitation facilities • Free-standing long term acute care facilities • Free-standing psychiatric facilities • Indian Health Service facility or tribally operated 638 facility • Transplant services under AHCCCS contract lcollingwood Sept 2014

Current versus Future Beginning on October 1, 2014 AHCCCS AHCCCS has historically will begin using a DRG-based model to reimbursed claims for inpatient reimburse for hospital inpatient services. services using a tiered per diem fee schedule which was inflated annually using a nationally recognized inflation factor. Current AHCCCS Reimbursement Reimbursement change as of Model October 1, 2014 • DRG- based model termed • Tiered per diem fee for service APR-DRG model • Inflated annually lcollingwood Sept 2014

APR-DRG: All Patient Refined Diagnosis Related Groups Description: • A classification system that requires patients to be classified according to: 1) Reason for admission 2) Severity of illness (SOI) 3) Risk of mortality (ROM) * Each case is assigned an SOI (1-4) and an ROM (1-4) *The determination of the SOI and ROM is disease specific *Use of the SOI and ROM provides a more accurate picture of resource use and outcomes. • Underlying Principles – The patient’s severity of illness (SOI) and risk of mortality (ROM) are both dependent on the underlying problem (i.e. the base DRG) – High Severity of Illness and Risk of Mortality are characterized by multiple serious diseases and by the interaction of those disorders lcollingwood Sept 2014

Snapshot of how APR-DRG works Instructions 1. Review the primary and secondary diagnoses in each column below . 2. As you move from the left column to the furthest right column, pay attention to the changes in the information that is located in the grey sections at the bottom of each column as the diagnoses and the specificity of documentation changes. Co-morbid Primary dx: Primary dx: Primary dx: Primary dx: Primary dx: conditions increase Pneumonia Sepsis Sepsis Sepsis Sepsis the SOI. Secondary dx: Secondary dx: Secondary dx: Secondary dx: Secondary dx: Bacteremia Pneumonia Pneumonia Klebsiella Klebsiella The Pneumonia Pneumonia increase in Diastolic CHF SOI Diastolic CHF Diastolic CHF reflects the difficulty Acute and costs Respiratory that are Failure involved in APR DRG 139 APR DRG 720 APR DRG 720 APR DRG 720 APR DRG 720 treating SOI 2 SOI 2 SOI 2 SOI 3 SOI 4 the ROM 2 ROM 2 ROM 3 ROM 3 ROM 4 patient. RW: 0.5793 RW: 0.7113 RW: 0.7113 RW: 1.1700 RW: 2.7338 Note 3. Remember that payment is determined by the Severity of Illness (SOI) . 4. When documentation of the primary and secondary diagnoses is specific & detailed, the occurrence of appropriate coding and appropriate reimbursement of claims improves significantly. lcollingwood Sept 2014

APR-DRG Payment Key Points APR-DRG payments shall be the sole reimbursement for • all inpatient services to AHCCCS patients:  Services provided in the ER, observation, or other outpatient department that are directly followed by inpatient admission to the same hospital are not paid separately  No other services or supplies will be carved out or separately reimbursed lcollingwood Sept 2014

Three Provider Actions that are Critical to APR DRG • Documentation in the patient record must be detailed and specific to minimize reimbursement delays or denials • Primary and secondary diagnoses must be clearly documented with a high degree of specificity • Diagnoses that are present on admission must be clearly indicated lcollingwood Sept 2014

APR DRG Transition Successful transition to APR DRG is dependent on documentation specificity for all diagnoses and procedures. This facilitates accurate coding which in turn ensures appropriate reimbursement. lcollingwood Sept 2014

Contacts for more detailed Information AHCCCS website: http://www.azahcccs.gov/commercial/ProviderBilling/DRGB asedPayments.aspx Subscribe to the AHCCCS List Serve at http://listserv.azahcccs.gov/cgi-bin/wa.exe?A0=APRDRG-L Select “join” on the right side of the page e-mail questions and comments to: DRG@AZAHCCCS.gov lcollingwood Sept 2014