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

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Current versus Future

Current AHCCCS Reimbursement Model

• Tiered per diem fee for service

model

• Inflated annually

Reimbursement change as of October 1, 2014

• DRG- based model termed

APR-DRG

AHCCCS has historically reimbursed claims for inpatient services using a tiered per diem fee schedule which was inflated annually using a nationally recognized inflation factor. Beginning on October 1, 2014 AHCCCS will begin using a DRG-based model to reimburse for hospital inpatient services.

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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

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Snapshot of how APR-DRG works

Primary dx: Pneumonia Primary dx: Sepsis Primary dx: Sepsis Primary dx: Sepsis Primary dx: Sepsis Secondary dx: Bacteremia Secondary dx: Pneumonia Secondary dx: Pneumonia Diastolic CHF Secondary dx: Klebsiella Pneumonia Diastolic CHF Secondary dx: Klebsiella Pneumonia Diastolic CHF Acute Respiratory Failure APR DRG 139 SOI 2 ROM 2 RW: 0.5793 APR DRG 720 SOI 2 ROM 2 RW: 0.7113 APR DRG 720 SOI 2 ROM 3 RW: 0.7113 APR DRG 720 SOI 3 ROM 3 RW: 1.1700 APR DRG 720 SOI 4 ROM 4 RW: 2.7338

• 3. Remember that payment is determined by the Severity of Illness (SOI).
• 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.

• 4. When documentation of the primary and secondary diagnoses is specific & detailed,

the occurrence of appropriate coding and appropriate reimbursement of claims improves significantly. Co-morbid conditions increase the SOI. The increase in SOI reflects the difficulty and costs that are involved in treating the patient.

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Instructions Note

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
• utpatient 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

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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

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APR DRG Transition

Successful transition to APR DRG is dependent

• n documentation specificity for all diagnoses

and procedures. This facilitates accurate coding which in turn ensures appropriate reimbursement.

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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

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