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
Current versus Future 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. Current AHCCCS Reimbursement Model Tiered per diem fee for service model Inflated annually Beginning on October 1, 2014 AHCCCS will begin using a DRG-based model to reimburse for hospital inpatient services. Reimbursement change as of October 1, 2014 DRG- based model termed APR-DRG
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
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. Primary dx: Pneumonia Secondary dx: Primary dx: Sepsis Secondary dx: Primary dx: Sepsis Secondary dx: Primary dx: Sepsis Secondary dx: Primary dx: Sepsis Secondary dx: Co-morbid conditions increase the SOI. Bacteremia APR DRG 139 SOI 2 ROM 2 RW: 0.5793 Pneumonia APR DRG 720 SOI 2 ROM 2 RW: 0.7113 Pneumonia Diastolic CHF APR DRG 720 SOI 2 ROM 3 RW: 0.7113 Klebsiella Pneumonia Diastolic CHF APR DRG 720 SOI 3 ROM 3 RW: 1.1700 Note 3. Remember that payment is determined by the Severity of Illness (SOI). Klebsiella Pneumonia Diastolic CHF Acute Respiratory Failure APR DRG 720 SOI 4 ROM 4 RW: 2.7338 The increase in SOI reflects the difficulty and costs that are involved in treating the patient. 4. When documentation of the primary and secondary diagnoses is specific & detailed, the occurrence of appropriate coding and appropriate reimbursement of claims improves significantly.
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
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
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.
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