Transcript An Overview of 3MTM All Patient Refined Diagnostic Related

An Overview of 3MTM All Patient Refined
Diagnostic Related Groups (3M APR DRG)
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Lisa Lyons, Product Marketing Manager
3M HIS
July 13, 2012
3M Health Information Systems
3M APR-DRG Education Session Agenda
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Introduction to APR DRG
Differences between MS DRG and APR DRG
APR-DRG clinical logic primer
Uses of APR-DRGs.
Steps for Your Organization’s Success.
Frequently Asked Questions
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3M Approach
Set the right
foundation
Improve Quality
Outcomes
• 3M All Patient
Refined
Diagnostic
Related
Groups
• Acute Care Outcomes
• 3M Potentially
Preventable
Complications
• 3M Potentially
Preventable
Readmissions
• 3M Enhanced
Ambulatory
Groups
• Community
Outcomes
Understand the
overall burden
of illness you
carry
Understand
your total
cost of care
• 3M Clinical Risk
Groups
• CMS Episodic
Grouper
• 3M Potentially
Preventable ED Visits
• 3M Potentially
Preventable Initial
Admissions
• 3M Potentially
Preventable Ancillary
Services
Value Based Health Care
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• 3M Patient
centered
episode
grouper
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The Internet Dynamic- reputation
3 most popular
reasons for going
online:
1.Checking Email
2.Search engines
3.Search healthcare
information.
66%
Look up
information on
specific
conditions
44%
Doctors or
other health
professionals
comparisons.
36%
Hospitals or other
medical facilities
comparisons
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Importance of Understanding Risk Adjusted Data
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How are 3M Methodologies updated?
• Clinical Panels review clinical logic for needed adjustments
• Hospitals
• State Agencies input
• New literature evaluated
• New code set
• Data is run to validate changes
• 2 tier Peer review of changes are reviewed
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Difference between CMS MS DRG and 3M APR DRG
MS DRG
 Data Source - Medicare
 Coverage- 65+ years old
 3 levels of severity
 Not all conditions contain 3
levels of severity
 No risk categorization for risk of
dying
 Intended for reimbursement
only
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APR DRG
 Data Source- All payer
 Coverage includes all ages
 4 levels of severity
 All conditions have 4 levels of
severity
 4 levels of risk of mortality for
every condition.
 Used in both reimbursement
and quality performance
measurement
© 3M 2011 - 3M Confidential - For Customer's Internal Review Only. Further use or disclosure requires prior approval from 3M.
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What are APR DRGs?
 All Patients Refined Diagnosis Related Groups (APR DRG) is
a classification system that classifies patients according to
their reason of admission, severity of illness and risk of
mortality.
 The patient characteristics used in the definition of the DRGs are
limited to information routinely collected on hospital abstract
systems.
 There are a manageable number of DRGs which encompass all
patients seen on an inpatient basis.
 Each DRG contains patients with a similar pattern of resource
intensity.
 Each DRG contains patients who are similar from a clinical
perspective.
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Summary of APR DRGs
25 MDCs
MDC
Severity of Illness
is used for
payment
314 APR DRGs +
Subdivide each base APR
2 error DRGs
DRG into subclasses
Four Severity of Illness Subclasses
Four Risk of Mortality Subclasses
1.
Minor
1.
Minor
2.
Moderate
2.
Moderate
3.
Major
3.
Major
4.
Extreme
4.
Extreme
1256 Subclasses
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1256 Subclasses
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Key Definitions
 Severity of Illness: the extent of physiologic decompensation
or organ system loss of function
 Risk of Mortality: the likelihood of dying
 Resource Intensity: the relative volume and types of
diagnostic, therapeutic and bed services used in the
management of a particular disease
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SOI and ROM are Independent
The severity of illness and risk of mortality subclass are
calculated separately and may be different from each
other.
Acute
Cholecystitis
SOI = 3
Significant Organ
Decompensation
ROM = 1
Low risk of mortality
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Example of Severity of Illness
Progression of Diagnoses
Severity
Of Illness
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Secondary Diagnosis of
Diabetes Mellitus
1
Minor
Uncomplicated Diabetes (250.0X)
2
Moderate
Diabetes with Renal Manifestation (250.4X)
3
Major
Diabetes with Ketoacidosis (250.1X)
4
Severe
Diabetes with Hyperosmolar Coma (250.2X)
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Fundamental Principle of APR DRG Clinical Logic:
 Severity of illness and risk of mortality are dependent on the
patient’s underlying condition (i.e., the base APR DRG).
 High severity of illness and risk of mortality are
characterized by multiple serious diseases and the
interaction of those diseases.
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Explanation of APR DRG Methodology
• Assign the base APR DRG
Phase 0
• Determine level of each secondary diagnosis
Phase I
6 steps
• Determines a base subclass for the patient based
on all of the patient’s secondary diagnoses
3 steps
Phase II
• The final subclass for the patient is determined
Phase III
18 steps total
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9 steps
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Assign the Base
APR DRG
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SOI Phase I:
Step 1
Eliminate secondary diagnoses (SDX) that are
associated with principal diagnosis (PDX)
Phase I
Determine level
of each
secondary
diagnosis
Step 2
Assign each secondary diagnosis its standard
severity of illness (SOI)
1-Minor 2-Moderate 3-Major 4-Extreme
Modify the standard severity of illness of each
secondary diagnosis based on:
Step 3 Age
Step 4 APR DRG and PDX (DRG 190)
Step 5 APR DRG
Step 6 Non-OR procedures
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SOI Phase II:
Step 7
Eliminate SDXs that are redundant with
other SDXs.
Phase II
Determines a base
subclass for the
patient based on all
of the patient’s
secondary
diagnoses
Step 8
Combine all SDX to determine the base SOI
subclass for the patient.
(Highest SOI used)
Step 9
Reduce the subclass of patients in
level 3 or 4 to next lower subclass if no
multiple secondary diagnoses at a high
severity of illness level exist.
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SOI Phase III:
Modify patient SOI subclass based on the interaction of
Step 10
Step 11
Step 12
Step 13
APR DRG and PDX
APR DRG and age or APR DRG and PDX and age
APR and non-OR procedure
APR DRG and OR procedure
Modify patient SOI subclass based on the interaction of
Step 14 APR DRG and pairs of OR procedures
Step 15 APR DRG and ECMO and presence/absence
of certain OR procedures (DRG 583)
Step 16 APR DRG and PDX and non-OR procedures
Phase III
The final subclass for
the patient is
determined
Step 17
Establish a minimum SOI subclass based on
the presence of specific combinations of
categories of SDXs.
Step 18
Compute the final SOI subclass based on a
hierarchy established for steps 9-17
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MDC 15 Criteria
 Age at admission = 0 - 7 days
 Age at admission = 8 -14 days and birthweight <1,000 grams
 Age at admission = 8 -14 days, birthweight 1,000 -1,999 grams,
and procedure from MDC 15 list of major O.R. procedures
 Age at admission = 8 -14 days, birthweight 1,000 -1,999 grams,
and mechanical ventilation (procedure codes 9670, 9671 and
9672)
 Age at admission = 8 -14 days and principal diagnosis of an
acute perinatal problem
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New criteria for low birth weight babies…
 DRG 589- Neonate BWT <500G or GA <24 weeks
 MDC 15 neonates who do not meet the criteria for DRGs 580,581, 583, or 588,
and
 Birthweight < 500 grams- (PDX, SDX, or entered*), or
 Birthweight 500-999 grams (PDX, SDX, or entered*) and gestational age <24
weeks (PDX or SDX of 76521), or
 Birthweight 500-749 grams (PDX,SDX, or entered*) and does not have any life
sustaining non-O.R. premature newborn intervention procedures as listed
 For SOI and ROM assignment, DRG 589 will bypass the usual 18 step algorithm
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PDX: 562.11 Diverticulitis of colon
Proc: 45.71 Multiple segmental resection of large intestine
Case 1
Secondary
Diagnoses
569.41
Case 2
569.41
560.9
Case 3
569.41
560.9
422.99
426.0
Case 4
569.41
560.9
422.99
426.0
584.9
CMS DRG
149 wo CC
148 w CC
148 w CC
148 w CC
APR DRG
221 Subclass 1
221 Subclass 2
221 Subclass 3
221 Subclass 4
4.2303
1.7681
4.2303
2.9531
4.2303
6.3732
CMS DRG
APR DRG
2.3164
1.3322
Description
Ulcer of anus and rectum
Unspecified intestinal obstruction
Acute myocarditis
Atrioventricular block, complete
Acute renal failure, unspecified
Major small and large
bowel procedures
Payment weights*
* Payment weights are budget neutral and computed from a national database
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PDX V3000: Single liveborn, born in hospital, delivered without
mention of cesarean section
Admission age in days: 0
Discharge status: Home
Birthweight: 500G
Case 1
Case 2
Secondary
Diagnoses
CMS DRG
APR DRG
Case 3
748.4
391
591 Subclass 1
Case 4
748.4
770.8
748.4
770.8
753.0
390
389
389
591 Subclass 2
591Subclass 3
591 Subclass 4
Description
Congenital Cystic Lung
Respiratory Failure of NB
Renal Agenesis
Normal Newborn/ Newborn with
other significant problems/Full
Term Neonate w/ Maj. Prob.
Neonate, birth weight 500-749G,
without major procedure
CMS DRG
APR DRG
0.2560
0.1134
0.2892
2.6320
0.6430
12.8901
0.6430
23.1141
Payment weights*
* Payment weights are budget neutral and computed from a national database
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How is Chocolate Cake like APR DRG’s?
3M Health Information Systems
Keys to Success
1. Complete and Accurate coding ( including POA)
 Changes to HIM productivity may be needed
2. Documentation Improvement/Concurrent review
3. Use APR DRG throughout organization
4. Know where you stand - Monitor rates
5. Tools to analyze your data - Distribution Matters
3M Health Information Systems
CMS DRG to APR DRG Migration
Complete and
Accurate Coding
•Coders strong in
anatomy, physiology,
and patho-physiology
•Coders benefit from
seeing grouped data
Concurrent
Review of
Documentation
Provides early
dialog and
queries for
most accurate
data
Accurate
representation of
CMI
Allows data to
be used for
performance,
finance and
quality and IT
Clinical Specificity
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Common
Language for
entire
organization
3M Health Information Systems
Severity-Based Index Example
Hospital E
Hospital D
0
0.2
0.4
0.6
0.8
Severity-Adjusted Average Length of Stay and Cost
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1
1.2
Hospital C
Hospital A
L 5
O
S
4
Hospital B
3
$7,000
$11,000
COST
$15,000
Data Source: 3M APR DRG Classification System utilizing MEDPAR 2007 data
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$19,000
3M Health Information Systems
Severity Index Distribution for APR DRG
Peer Group
APR DRG
Subclass
1
2
3
4
Total
Cases
202
2,058
1,713
227
4,200
% of
Cases
4.8%
49.0%
40.8%
5.4%
100%
Average Severity Index
4.4374
Hospital A
APR DRG
Subclass
1
2
3
4
Total
Cases
44
102
33
4
183
Average Severity Index
% of
Cases
24.0%
55.7%
18.0%
2.2%
100%
4.0424
On average, 55% of cases in the peer group are paid without a MCC
vs. Hospital A, which has 80% of their cases without a MCC
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Data Source: 3M APR DRG Classification System utilizing MEDPAR 2007 data
© 3M 2009. All rights reserved.
Variance
-9.3%
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Who Uses APR DRGs:
Groups using the APR DRG
Providers
Quality Improvement
Clinical Improvement
Utilization Management
Strategic Planning
Operations/Finance
Payers
Managed care
States
Consumer
Public Reporting
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Why is Risk Adjustment so important for Analytics?
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Allows for apples to apples comparisons
Make data more actionable
Can be quantifiable
Ties quality outcome to financial performance
Better analytics
More accurate trending
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3M Health Information Systems
Potentially Preventable Complications Profile
4 Hospital System Example:
$6.4M Annual PPC
Cost
$4.9M (77%)
represents the top 10
3M Health Information Systems
PPR rates by SNF and Relative Severity.
Readmission Rate
Avg Relative Weight of Initial Admissions
Total New Admissions
3.75
180
3.50
160
3.25
3.00
140
2.75
2.50
120
2.25
100
2.00
1.75
80
1.50
1.25
60
1.00
40
0.75
0.50
20
0.25
0.00
0
SNF 25
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SNF 3
SNF 9
SNF 23 SNF 17 SNF 21 SNF 19 SNF 13
SNF 5
SNF 1
SNF 7
SNF 27 SNF 11 SNF 15
© 3M 2011 - 3M Confidential - For Customer's Internal Review Only. Further use or disclosure requires prior approval from 3M.
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Who Uses APR DRGs:
Groups using the APR DRG
Providers
Quality Improvement
Clinical Improvement
Utilization Management
Strategic Planning
Operations/Finance
Payers
Managed care
States
Consumer
Public Reporting
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APR DRG is used for NJ gain sharing pilot
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Case study of how to calculate a reimbursement from APR DRG and SOI.
Formula
APR DRGSOI
139-1
139-2
139-3
139-4
220-1
220-2
220-3
220-4
540-1
540-2
540-3
540-4
541-1
541-2
541-3
541-4
609-1
609-2
609-3
609-4
955-0
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956-0
Base
Rate
Ex: $8200
Relative
Wt by
Est. Reimb.
$$
APR/SOI
APR-DRG Description
OTHER PNEUMONIA
OTHER PNEUMONIA
OTHER PNEUMONIA
OTHER PNEUMONIA
MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES
MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES
MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES
MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES
CESAREAN DELIVERY
CESAREAN DELIVERY
CESAREAN DELIVERY
CESAREAN DELIVERY
VAGINAL DELIVERY W STERILIZATION &/OR D&C
VAGINAL DELIVERY W STERILIZATION &/OR D&C
VAGINAL DELIVERY W STERILIZATION &/OR D&C
VAGINAL DELIVERY W STERILIZATION &/OR D&C
NEONATE BWT 1500-2499G W MAJOR PROCEDURE
NEONATE BWT 1500-2499G W MAJOR PROCEDURE
NEONATE BWT 1500-2499G W MAJOR PROCEDURE
NEONATE BWT 1500-2499G W MAJOR PROCEDURE
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE
DIAGNOSIS
UNGROUPABLE
Relative Wt for
Payment
0.4022
0.6128
0.9459
1.8787
1.3302
2.0852
3.4859
7.2851
0.5400
0.6424
0.9728
2.3023
0.4955
0.5323
0.8258
2.5756
1.6898
4.7480
7.4462
14.4454
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DRG Base Payment
Using Example
Discharge Rate
$
3,298.04
$
5,024.96
$
7,756.38
$
15,405.34
$
10,907.64
$
17,098.64
$
28,584.38
$
59,737.82
$
4,428.00
$
5,267.68
$
7,976.96
$
18,878.86
$
4,063.10
$
4,364.86
$
6,771.56
$
21,119.92
$
13,856.36
$
38,933.60
$
61,058.84
$
118,452.28
$
$
-
3M Health Information Systems
Frequently Asked Questions
1. Why Non OR procedures?
2. Palliative Care - how is this considered in the ROM
assignment?
3. How many codes do you need for an accurate SOI?
4. Does the choice of principal diagnosis affect SOI and ROM?
5. What is the productivity difference of using APR DRG?
6. Will I see a difference in days to final bill?
7. What is the Admission APR DRG?
8. Do I need to use a different standard for coding?
9. Does APR DRG have interfaces to my HIS system?
10. Any other questions?
36
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3M Health Information Systems
Admission APR DRG
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Leverages POA
Adds seven steps to the APR assignment process
Used to Assign and risk adjust complication rates
Used to Risk Adjust Mortality Rates
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REFERENCE
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Characteristics of APR DRGs:
APRs are a statistically better methodology
APRs have increased payment categories to 1256
APR DRGs are transparent
Every secondary DX and all procedures are evaluated for their impact on a case
3 byte DRG + 1 byte SOI + 1 byte ROM
Effects are additive not absolute
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7/7/2015© 3M 2007. All rights reserved.
© 3M 2009. All rights reserved.
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Key APR Outputs:
Core Grouping Software (CGS) & Grouper Plus System (GPS) and
Mainframe Groupers
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DRG
MDC
SOI (subclass)
ROM (subclass)
Diagnosis SOI (level)
Diagnosis ROM (level)
 Diagnosis Affect DRG Flag
 Diagnosis Affect ROM
Flag
 Diagnosis Affect SOI Flag
 Procedure Affect DRG
Flag
 Procedure Affect ROM
Flag
 Procedure Affect SOI Flag
Full set of outputs available for both admission and discharge
APR DRGs
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3M Health Information Systems
3M Product Inputs & Outputs
 Only standard grouping inputs required
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Diagnoses with POA
Procedures
Patient age
Patient sex
Discharge status
Birthweight
 No change to grouper outputs
 Changes to reimbursement outputs not yet known, expected to be
simplified.
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3M Health Information Systems
Products
 3M TM APR DRG grouping software
 Interactive – allows you to see the grouped information at the point of
coding
 Batch – Core grouping software – allows you to send a batch file of
abstracted data to report grouping information.
 3M TM Advanced Analyzer Software
 Works with Coding and Reimbursement system to assist in complete
and accurate coding.
 3M TM 360 Encompass suite
 Assists HIM departments in more accurate documentation, coding and
higher productivity.
 Other products and services are available.
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