Transcript Diagnosis Related Groups (DRGs)

Diagnosis Related Groups
(DRGs)
Diagnosis Related Group

DRG Diagnosis Related Group. A "Diagnosis Related
Group" is a payment category that is used to classify
patients, especially Medicare patients, for the purpose of
reimbursing hospitals for each case in a given category
with a fixed fee regardless of the actual costs incurred. A
DRG is based upon the principal ICD-9-CM diagnosis code,
ICD-9-CM surgical procedure code, age of patient, and
expected length of stay in the hospital that will be
reimbursed, independently of the charges that the hospital
may have incurred
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DRG OVERVIEW:
The American health care system was quite different
than it is today. Back in the 1950s not everyone had
health insurance, mostly those who did had either
private insurance or BC/BS (Blue Cross/Blue Shield). In
the 1960s Medicare and Medicaid was created.
In the 1970s, there was a lot of distrust for the U.S.
government including lack of confidence in the
American medical system. There were many without
insurance and a great number of companies did not
offer health care benefits. President Nixon created
Managed Care Organizations (MCOs), which required
companies to provide health insurance for their
employees.
What really transformed is the way in which inpatient health
care would be reimbursed in the 1980s. Health care costs were
out of control. Facilities were being reimbursed for what
services they provided regardless of cost (fee for service or time
rendered) and there was no incentive for them to streamline
costs. Congress implemented the UB-82 (now UB-92) to create
one claim form for all insurance agencies for inpatient
services.
The DRG system was created in 1983 to cut costs for Medicare
patients. The DRG system is a patient classification system that
groups patients with similar diagnoses and/or procedures into
the same category. The facility is then reimbursed with a lump
sum payment based on this category, figuring on average what
it would cost to treat a patient with a diagnosis. Congress also
required that facilities have an active Utilization Review and
Quality Assurance Department to evaluate the quality of care
patients are receiving and how that care is utilized (how much
resources are used) to care for the patient.
History
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In the mid 1970s the Centre for Health
Studies at Yale University began work on a
system for monitoring hospital utilisation
review. Following a 1976 trial of a DRG
system, it was decided to base the final
system on the ICD-9-CM which would provide
the basic diagnostic categories
Purpose.
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relate a patient’s diagnosis and treatment to the
cost of their care
Developed in the United States by the Health
Care Finance Administration
DRGs are used for reimbursement in the
prospective payment system of US Medicare
and Medicaid healthcare insurance systems
DRGs were designed to support the calculation
of federal reimbursement for healthcare
delivered through the U.S. Medicare system
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A patient’s principal diagnoses and the procedures
they are treated with during hospital admission are
used to select the group in the DRG classification that
most appropriately describes they overall type of care
that has been delivered.
Diagnosis Related Groups (DRG) are a system
classifying in-hospital patient cases into categories
with similar resource use. The grouping is based on
diagnoses, procedures performed, age, sex and status
at discharge
Next the group selected is associated with a typical
cost. Specifically, DRG funding requires the use of a
cost weighting that is applied by the funding agency to
determine the actual amount that should be paid to an
institution for treating a patient with a particular DRG.
The weightings are determined by a formula that is
typically developed on a state or national basis.
DRG Structure
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Major Diagnostic category
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Medical Surgical split
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Complications & Comorbidities
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Exclusion list
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Structure diagram
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DRG Example with severity score
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Major Diagnostic Category Assignment
(MDC)
The initial step in the determination of the
DRG has always been the assignment to
the appropriate MDC based on the
Principal Diagnosis
Since the presence of a surgical
procedure requires different hospital
resources (operating room, recovery
room, anesthesia) most MDCs were
initially divided into medical and surgical
groups
Medical Surgical split
All procedure codes were classified based
on whether or not they required the use of
an operating room
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Operating room procedures
– Cholecystectomies
– Cerebral meninges biopsies
– Closed heart valvotomies
Non operating room procedures
– Bronchoscopy
– Skin sutures
Complications & Comorbidities
(CCs)
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A complication is a condition which did not
exist prior to the admission
A comorbidity is a condition which existed
prior to admission
A complication or comorbidity is a secondary
diagnosis which would be expected to extend
the patient’s length of stay by at least one
day in at least 75 percent of patients
Major CCs
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Within each MDC patients with major CCs
(e.g., AMI, CVA, etc.) were assigned to
separate DRGs, and as part of the
Severity Level process of IR-DRGs
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A major complication or comorbidity is a
secondary diagnosis which would be
expected to extend the patient’s length of
stay by at least 3-4 days in at least 75
percent of patients
Complication & Comorbidity
(CC) Exclusion List
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For a principal diagnosis of bladder
neck obstruction
– Urinary retention is not a CC
For a principal diagnosis of general
convulsive epilepsy
– Convulsion is not a CC
DRG Classification - Example
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Principal Diagnosis 41091: AMI NOS,
Initial
MDC 5 Diseases and Disorders of the Circulatory
System
Operating Room Procedure 3761:Pulsation
Balloon Implant
DRG 110: Major Cardiovascular Procedures with
CC or
DRG 111: Major Cardiovascular Procedures
without CC or
DRG 549: Major Cardiovascular Procedures with
Major CC
Secondary Diagnosis
1) 25000: Diabetes Mellitus Type II without
Complications
- CC : No
- Major CC : No
- DRG : 111
DRG Classification - Example 2
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Principal Diagnosis 41091: AMI NOS, Initial
MDC 5 Diseases and Disorders of the Circulatory System
Operating Room Procedure 3761:Pulsation Balloon Implant
DRG 110: Major Cardiovascular Procedures with CC or
DRG 111: Major Cardiovascular Procedures without CC or
DRG 549: Major Cardiovascular Procedures with Major CC
Secondary Diagnosis
1) V434: Blood Vessel Replacement Not Elsewhere
Classified (NEC)
- CC : No
- Major CC : No
2) 7100: Systemic Lupus Erythematosus
- CC : Yes
- Major CC : No
- DRG: 110
DRG Classification - Example 3
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Principal Diagnosis 41091: AMI NOS, Initial
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MDC 5 Diseases and Disorders of the Circulatory
System
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Operating Room Procedure 3761:Pulsation Balloon
Implant
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DRG 110: Major Cardiovascular Procedures with CC or
DRG 111: Major Cardiovascular Procedures without CC or
DRG 549: Major Cardiovascular Procedures with Major CC
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Secondary Diagnosis
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1) 78551: Cardiogenic Shock
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- CC : No
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- Major CC : Yes
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- DRG : 549
Surgical Hierarchy
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If multiple procedures are present, the
patient is assigned to a single surgical
DRG based on a surgical hierarchy
within each MDC
‫‪DRG Structure‬‬
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‫ساختار كلي ‪ DRG‬از ‪ 3‬جزء تشكيل شده كه عبارتند از‪:‬‬
‫‪ PreMDC‬كه همان قسمت استثناء ‪ DRG‬است‬
‫‪ MDC‬كه همان قسمت اصلي است‬
‫‪ ErrorDRG‬كه از نظر اطالعات بهداشتي ناقص است‪ .‬به‬
‫عبارت ديگر يا اطالعات موجود در پرونده متناقض يا غير معتبر‬
‫است و يا تشخيص گزارش شده دقيق و كامل نيست و نمي توان كد‬
‫‪ DRG‬خاصي به آن اختصاص داد‪ .‬اين كدها عبارتند از‪:‬‬
‫• كد ‪ :468‬اگر بيماري به علتي در بيمارستان بستري شود و به علت‬
‫ديگري مورد عمل جراحي قرار گيرد‪،‬كد ‪ DRG468‬به آن اختصاص‬
‫مي يابد‪.‬مثال بيماري كه با تشخيص اصلي نارسايي احتقاني قلب بستري‬
‫شده اما بدليل التهاب كيسه صفراي رو به پيشرفت ‪ ،‬اقدام جراحي خارج‬
‫ساختن كيسه صفرا براي وي انجام شده است‪.‬‬
‫• باشد با كد ‪ DRG 470‬مشخص مي شود‪.‬‬
‫‪DRG Structure‬‬
‫• كد ‪ :469‬زماني كه تشخيص اصلي انتخاب شده به اندازه‬
‫كافي دقيق و درست نيست تا بتوان كد خاصي از ‪ DRG‬را‬
‫به بيمار اختصاص داد از اين كد استفاده مي شود‪ .‬حتي اگر‬
‫كدي از ‪ ICD‬براي آن مورد در نظر گرفته شود‪ .‬مثال كد‬
‫‪ 646.90‬در ‪ ICD-9-CM‬نشان دهندة عوارض نامشخص‬
‫پيش از زايمان‪ ،‬هنگام زايمان و پس از زايمان است‪ .‬در‬
‫‪ DRG‬بايد اطالعات نشان دهد در كدام مرحله از مراقبت‬
‫عارضه ايجاد شده است و در صورتي كه مشخص نباشد‪ ،‬كد‬
‫‪ DRG 469‬به آن اختصاص مي يابد‪.‬‬
‫• كد ‪ :470‬اشتباهات ثبت شده در گزارش هاي پزشكي كه‬
‫ممكن است بر تخصيص كد ‪ DRG‬اثر بگذارد با اين كد‬
‫مشخص مي شود‪ .‬مثال بيماري كه در گزارشات سن وي‬
‫‪ 154‬سال گزارش شده‪ ،‬در صورتي كه انتخاب كد با سن‬
‫بيمار بستگي داشته‬
DRG assignment
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The first step in DRG assignment is the classification of
discharges by Major Diagnostic Category (MDC). There are
25 MDCs which are essentially primary diagnostic
groupings generally based on the body systems, e.g.
nervous system (MDC 1), eye (MDC 2), circulatory system
(MDC 5), etc.
There are some exceptions where the classification by
MDC does not follow this pattern, for example MDC 14:
Pregnancy, Childbirth, and the Puerperium, MDC 24:
Multiple Trauma, and MDC25: HIV Infection.
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Following assignment to the MDC, discharges are assigned
to the DRG level. Discharges with a surgical procedure
performed are assigned to the surgical DRGs where
classification is based on the most resource intensive
performed. Medical discharges are assigned to a
DRG on the basis of the principal diagnosis.
Further classification within these groups arise if
particular variables, like the presence of
complications/comorbidities (ccs), age, or discharge
status are found to have a significant influence on
the treatment process and/or the pattern of
resource utilisation.
Some exceptions to the general approach for DRG
classification do exist, for example, discharges
receiving liver or bone marrow transplants and
discharges with temporary tracheostomies being
assigned to DRGs outside of the MDC framework
DRG assignment
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A DRG is assigned based on the patient's diagnosis
(ICD-9-CM coding). The encoder (also known as the
DRG grouper) is a software program developed by
CMS that places the patient into a Major Diagnostic
Category based on the diagnosis.
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For example: A patient with a fracture would be
grouped to the Musculoskeletal Major Diagnostic
Category. At this point, the patient is considered a
medical DRG. If the patient has a surgical procedure,
then the patient is grouped to a surgical DRG. The
other factors that influence DRG assignment is age of
the patient, any complication/comorbidities, and
discharge status.
Illustration of DRG-grouping,
patient > 17 years
Major diagnosis ICD10 S72.0:
Fracture of the collum femoris
MDC 08:
Rheumatic diseases
Surgical procedures
No
Yes
Amputation
Type of surgery
NCSP 50
Marrow nailing
Biopsy
Secondary
diagnosis
Yes
DRG 236:
Hip/pelvis
fracture
DRG 213:
Amputations
DRG 211:
Hip/thigh bone
operation
DRG 210:
Hip/thigh bone
operation
DRG 216:
Biopsies
(rheumatic diseases)
‫‪DRG assignment‬‬
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‫كدهاي ‪ ICD‬بر اساس سيستم هاي بدن يا تخصص در گروه هاي تشخيصي اصلي [‪] 1‬‬
‫قرار مي گيرند‪.‬‬
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‫افرادي كه پس از عمل جراحي مرخص شده اند در گروه جراحي و كساني كه عمل‬
‫جراحي نداشته اند در گروه پزشكي قرار مي گيرند‪.‬‬
‫‪‬‬
‫كساني كه در گروه جراحي قرار مي گيرند بر اساس ميزان مصرف منابع به چند گروه‬
‫تقسيم مي شوند‪ .‬بيماراني كه چند عمل جراحي داشته اند‪ ،‬بر اساس پرهزينه ترين‬
‫جراحي طبقه بندي مي شوند‪ .‬مثال اگر اقدام كورتاژ و ديالتاسيون[‪ ]2‬و خارج كردن‬
‫رحم[‪ ] 3‬بطور همزمان بر روي بيمار انجام شود‪ ،‬چون ذرآوردن رحم نياز به تدابير‬
‫بيشتري دارد‪ ،‬به عنوان اقدام پر هزينه تر انتخاب مي شود‪.‬‬
‫‪DRG assignment‬‬
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‫كساني كه در گروه پزشكي قرار گرفته اند بر اساس تشخيص اصلي به‬
‫گروه هاي فرعي مانند نئوپالسم و‪ ...‬تقسيم مي شوند‪.‬‬
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‫در اين گروه ها بيماراني كه به روش هاي مشابه و توسط متخصصين‬
‫مشابه درمان مي شوند‪ ،‬در يك گروه ‪ DRG‬قرار مي گيرند‪.‬‬
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‫براي گروه بندي نهايي از تشخيص اصلي‪ ،‬عوارض ‪ ،‬بيماري هاي همراه‬
‫‪ ،‬سن بيمار‪ ،‬جنس بيمار و وضعيت هنگام ترخيص (مرده‪ ،‬زنده‪ ،‬پيگيري‬
‫بعدي) استفاده مي كنند‪.‬‬
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‫)‪[1] Major Diagnostic Category (MDC‬‬
‫)‪]2[ Dilatation & Curettage (D&C‬‬
‫‪]3[ Hysterectomy‬‬
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‫‪Example‬‬
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‫بيماري با تشخيص ديابت (شروع در بزرگسالي ) و كوليك‬
‫حاد شكمي پذيرش شده است‪ .‬پيگيري هاي بعدي سنگ كيسه‬
‫صفرا را نشان داده است‪ .‬براي بيمار خارج كردن كيسه صفرا‬
‫و جستجوي مجاري صفراوي انجام شده است‪ .‬ديابت بيمار‬
‫اغلب مدت زماني كه بيمار در بيمارستان اقامت داشته است‬
‫خارج از كنترل بوده است‪.‬‬
‫سيستم بدني درگير‪ ،‬سيستم كبدي‪ -‬صفراوي و پانكراس بوده‬
‫است‪ .‬چون برروي بيمار عمل جراحي انجام شده است‪ ،‬اقدام‬
‫جراحي محسوب مي شود و هيچگونه عوارض يا بيماري‬
‫همزمان نداشته است‪.‬‬
DRG information for DRG-production and DRGreimbursement
DRG
DRG 236 m
DRG 213 s
DRG 211 s
Description
Fractura colli femoris
Amputation
Hip/thigh bone operation,
non large, non-compl,
>17 years old
DRG 210 s Hip/thigh bone operation,
non large, compl., > 17
years old
DRG 216 s Biopsy, rheumatic dis.
DRG
weight
1.03
2.53
DRG
price NKK
14,569
35,786
DRG
trim days
14
54
1.73
24,470
25
2.09
29,562
19
1.45
20,510
34
Source: Prisliste DRG 1999 med kodeveiledning. Social- and health department. Oslo, 1999
‫‪Payment calculation‬‬
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‫پس از مرخص شدن بيمار‪ ،‬پزشك تمامي تشخيص ها و درمان ها را روي‬
‫فرم مخصوص ثبت مي كند‪.‬‬
‫سپس كد مناسب ‪ ICD-9-CM‬توسط كدگذار تعيين و ثبت مي شود‪.‬‬
‫بخش حسابداري بيمارستان فرم صورتحساب را فراهم مي كند كه درآن فرم‬
‫اطالعات هويتي بيمار‪ ،‬كدهاي ‪ ICD-9-CM‬و ساير اطالعات ثبت مي‬
‫شود‪.‬‬
‫در مرحله بعد كارگزاران مالي صورتحساب يا ليست مورد نظر را ازجهت‬
‫خوانا بودن و تناسب كدها و صحيح بودن آنها بررسي مي كنند و بر اساس‬
‫كدهاي ‪ ICD-9-CM‬كد ‪ DRG‬تعيين مي شود‪.‬‬
‫هر گروه ‪ DRG‬يك ارزش نسبي دارد كه هزينه كليه خدمات و تجهيزات‬
‫مصرف شده براي بيمار را منعكس مي كند‪ .‬هرچه اين ارزش بيشتر باشد‬
‫منابع بيشتري مصرف شده و هزينه بيمار افزايش مي يابد‪ .‬ارزش نسبي‬
‫هر گروه ‪ DRG‬در بيمارستان هاي مشابه يكسان است‪.‬‬
‫‪‬‬
‫‪[1] Hospital rate‬‬
‫‪Payment calculation‬‬
‫‪‬‬
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‫مقدار پرداخت هزينه بيمارستاني در هر بيمارستان بر اساس عوامل‬
‫مختلف نظير نوع بيمارستان‪ ،‬جغرافيايي‪ ،‬روستايي يا شهري بودن‬
‫بيمارستان‪ ،‬اختالف نرخ دستمزد در نواحي مختلف و ساير عواملي‬
‫كه بر هزينه تاثير دارند تعيين مي شود ‪ ،‬اين مقدار نرخ بيمارستاني‬
‫[‪ ]1‬نام دارد كه ممكن است در سالهاي مختلف بر اساس نرخ تورم‬
‫تغيير كند‪ .‬قبال وضعيت آموزشي و تعداد تخت نيز در محاسبه هزينه‬
‫ها بحساب مي آمد ‪ ،‬ولي امروزه تاثير اين عوامل رد شده است‪.‬‬
‫لذا هزينه بيماران از حاصلضرب نرخ بيمارستاني در هزينه ثابت‬
‫بدست مي آيد‪ .‬به اين ترتيب بيمارستان مبلغ ثابتي را دريافت مي كند‬
‫‪ ،‬درصورتي كه هزينه بيمار كمتر از هزينه دريافتي باشد‪ ،‬بيمارستان‬
‫مي تواند مابه التفاوت را بعنوان سود ذخيره نمايد و بر عكس‬
‫چنانچه هزينه صرف شده براي بيمار بيشتر از مبلغ ‪ DRG‬باشد‪،‬‬
‫بيمارستان مجبور است خسارات وارده را متحمل شود‪ .‬اين امر‬
‫باعث مي شود بيمارستان ها ‪ ،‬بيماران سودمند را انتخاب كنند و از‬
‫درمان بيماران زيان آور خودداري كنند‪.‬‬
CODING AND ITS RELATION TO DRG ASSIGNMENT

Coding is a team approach.
If there is improper
documentation the facility, along with the physician, are
considered noncompliant in reflecting the patient's true
hospital course. Coding can only be done in an accurate,
timely, and ethical manner by using conclusive
documentation by physicians.

It is the role of the coder to go through the whole medical
record to locate all the information to accurately code
including
ethically
coding
complications
and
comorbidities. These conditions can be found in various
placed in the medical record. The medical record needs to
be comprehensive, legible, well-documented, and
completed in a timely fashion to be compliant. Lacking any
of these will place the facility in danger of being audited,
increasing the risk of fraud and abuse.
Inpatient Classification
Objectives

Aid in Clinical Management

Provide Equitable Resource Allocation
Method

Promote Efficiency & Effectiveness in
Managing Inpatient Care

Increase Accuracy in Reporting Workload
and Associated Costs
Develop a classification system
that is the basis for

Hospital Management

Budgeting


Benchmarking
Profiling

Clinical research

Quality reporting

Global comparison

Payment
Level of acceptance and use

DRGs are used routinely in the United
States for management review and payment
for Medicare and Medicaid patients. Given
the importance of reimbursement worldwide, DRGs have undergone ongoing
development, and have been adopted in one
form or another in many countries outside
the USA, including Australia (AR-DRG),
Canada (CMG) and countries of Europe and
Asia.
Classification structure

Patients are initially assigned a code from ICD-9 CM or a
clinical modification of ICD-10. ICD clinical modifications
are multiaxial systems closely based on the ICD structure.
Diagnoses are then partitioned into one of about 25 Major
Diagnostic Categories (MDCs) according to body organ
system or disease. The aim of this step is to group codes
into similar categories that reflect consumption of
resources and treatment .The categories are next
partitioned based upon the performance of procedures,
and on other variables such as the presence of
complications and co-morbidities, patient age, and length
of stay, before a DRG is finally assigned .There is thus a
process of category reduction at each stage, starting from
the many thousands of ICD codes to the few hundred
DRGs:
Limitations
DRGs and case-mix indices will always only give approximate
estimates of the true resource utilisation. For example, should a
hospital that is developing new and expensive procedures be paid the
same amount as an institution that treats the same type of patient
with a more common and cheaper procedure? Should quality of care
be reflected in a DRG? For example, if a hospital delivers good
quality of care that results in better patient outcomes, should it be
paid the same as a hospital that performs more poorly for the same
type of patient?
As importantly, those institutions that are best able to create DRGs
accurately are more likely to receive reimbursement in line with
their true expenditure on care. There is thus an implication in the
DRG model that an institution actually has the ability to accurately
assemble information to derive DRGs and a case-mix index. Given
local and national variations in information systems and coding
practice, it is likely that institutions with poor information systems
will be disadvantaged.
Developments

DRGs
are
designed
for
use
with
inpatients.
Accordingly, other systems have been developed for
other
areas
of
healthcare.
Systems
such
as
Ambulatory Visit Groups (AVGs) and Ambulatory
Payment Classifications (APCs) have been developed
for outpatient or ambulatory care in the primary sector.
These
are
based
upon
a
patient’s
intervention, visit status and physician time.
diagnosis,
The DRG Handbook, 2003
DRG audits
DRG audits may consists of evaluating
those DRGs that are incorrectly
used. These audits may also focus
on missing diagnoses, missing
procedures, and incorrect principal
diagnosis selection
For DRG based reviews, cases may be selected in a variety of ways:

• Simple random sample

• High dollar and high volume DRGs

• DRGs without comorbid conditions or complications

• Focused DRGs such as DRG 79 Pneumonia or DRG 416 Septicemia
and other high

risk DRGs

• Correct designation of patient discharge and transfer status
CPT audits
For physician services, hospital outpatient services, and
freestanding ambulatory surgery
centers, audits may focus on the following:

• Evaluation and management services for physician visits

• High volume and/or low volume outpatient surgeries

• Use of CPT modifiers on physician and outpatient claims

• Unlisted CPT codes

• Diagnosis codes on outpatient claims for medical
necessity of diagnostic services

• Accurate use of ICD-9-CM and CPT for ambulatory
surgery services
Ten DRGs with the highest
rates of upcoding











In its August 1998 report, Using Software to Detect Upcoding of
Hospital Bills, the Office of Inspector General lists the following
diagnosis-related groups as having the highest rates of upcoding.
87-pulmonary edema and respiratory failure
79-respiratory infections and inflammations with complicating
conditions (cc)
144-other circulatory system diagnoses with cc
239-pathological fractures and musculoskeletal and connective
tissue malignancy
429-organic disturbances and mental retardation
416-septicemia
475-respiratory system diagnosis with ventilator support
188-other digestive system diagnoses with cc
121-circulatory disorders with acute myocardial infarction and
cardiovascular complications, discharged alive
316-renal failure
case-mix


DRGs are also used to determine an
institution’s overall case-mix. The case-mix
index helps to take account of the types of
patient an individual institution sees, and
estimates their severity of illness. Thus a
hospital seeing the same proportion of patients
as another, but dealing with more severe
illness, will have a higher case-mix index
An institution’s case-mix index can then be
used in the formula that determines
reimbursement per individual DRG
‫‪Case mix calculation‬‬
‫‪‬‬
‫‪‬‬
‫بيماران مراجعه كننده به بيمارستان در يك دوره زماني خاص ( مثال يكسال) را در نظر‬
‫مي گيريم و مشخص مي كنيم هر بيمار در چه گروه ‪ DRG‬قرار گرفته است‪ .‬سپس‬
‫تعداد بيماران هر گروه ‪ DRG‬را در ارزش نسبي همان گروه ضرب مي كنيم‪.‬سپس اين‬
‫مقادير را با يكديگر جمع كرده و بر تعداد كل بيماران در آن دوره خاص تقسيم مي كنيم‪.‬‬
‫هر قدر عدد بدست آمده بزرگتر باشد‪ ،‬هزينه تمام شده براي هر بيمار بيشتر بوده و‬
‫بعبارت ديگر بيمارستان خدمات ارزنده تري را ارائه داده است‪.‬‬
‫مثال‪ :‬در يك دوره زماني خاص ‪ 1000 ،‬بيمار به بيمارستاني مراجعه كرده اند‪200 .‬‬
‫بيمار كد ‪ DRG 90 ، 450‬بيمار كد ‪ 50 ،89‬بيمار كد ‪ 410‬و ‪ 300‬بيمار كد ‪475‬‬
‫را به خود اختصاص داده اند‪ .‬ارزش نسبي اين كدها به ترتيب ‪،1447/1 ،./6990‬‬
‫‪ ./9363 ،134/5‬مي باشد‪ .‬كيس ميكس اينگونه محاسبه مي شود‪:‬‬
‫= ‪Case mix‬‬
‫)‪(200×6990/.)+(450×1447/1)+(300×134/5)+(50×9363/.‬‬
‫‪1000‬‬
‫‪Case mix =2/24‬‬
‫‪Example‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫دو بيمارستان با شرايط زير را مقايسه كنيد‪.‬‬
‫هر دو ‪ 200‬بيمار را پذيرش كرده اند‪.‬‬
‫در هر دو بيمارستان ‪ ،‬تعداد روزبيمار ‪ 1200‬روز بوده است‪.‬‬
‫متوسط اقامت بيماران حدود ‪ 6‬روز بوده است‪.‬‬
‫ظاهرا راندمان دو بيمارستان يكسان است‪ .‬اما با بررسي دقيق تر مشخص‬
‫مي شود در بيمارستان الف نيمي از بيماران با تشخيص فتق كشاله ران با‬
‫ارزش نسبي ‪ 0.5‬و نيم ديگر با تشخيص زخم معده پيچيده با ارزش نسبي‬
‫‪ 1.0‬بستري شده اند بنابر اين كيس ميكس چنين محاسبه مي شود‪:‬‬
‫‪ Case mix = (100×./5+(100×1) = 150‬‬
‫در بيمارستان ب ‪ 100‬بيمار با تشخيص جراحي باي پس با ارزش نسبي‬
‫‪ 5.5‬وبراي ‪ 100‬بيمار ديگر پيوند كليه با ارزش نسبي ‪ 3.84‬انجام شده‬
‫است‪ .‬بنابر اين كيس ميكس چنين محاسبه مي شود‪:‬‬
‫‪ Case mix = (100×5/5+100×3/84)= 934‬‬
‫به اين ترتيبب مقايسبه كبيس مبيكس هبا نشبان مبي دهبد بيمارسبتان ب تقريببا ‪9‬‬
‫برابر بيمارستان الف از منابع مصرف كرده است‪.‬‬
OPTIMIZATION AND CASE MIX


Optimization may not be gained if the coder is
inexperienced in reading the medical record,
understanding disease processes, unable to
understand where to look for additional information
such as drug usage, tests ordered, etc. By
providing the coder with ongoing education, this
increases the chance that increased
optimization. Optimization may also not be
possible due to lack or poor documentation and
poor team relationships.
Case mix is defined as the type of patients the
hospital treats. Facilities are very concerned on
whether their patients are making them money or
do they have a high percentage of patients in
which it costs the facility more to treat the patient
then what they are being reimbursed for.

Case-Mix System is very appropriate especially in justifying the
usage of optimum resources in tertiary care hospitals which
admits more severe cases. At present, the allocation of
resources to hospitals are among others based on the number
of beds and previous resource utilization without considering
efficiency and thus did not contribute to the improvement of
hospital efficiency. Case-Mix System also facilitates in the
implementation of quality enhancement programm in line with it
original objective of classification. Information on patients’
treatment such as length of stay helps in identifying differences
in treatment and problems in quality of patient care so it can be
highlighted and managed immediately. Hospitals are also
encouraged to
standardize the treatment process using clinical
guidelines and critical pathways in accordance to best
practices to ensure that patients receive the best and most
effective treatment.
The Government of Malaysia has decided to introduce a
national health care financing system to support the
increasing health care cost and to enhance equity,
accessibility, quality and efficiency in the health system.
One of the element in financing is the health care
provider payment mechanism based on this case-mix
system. Therefore, HUKM has taken the initiative to lead
the way in using case-mix system in this country and
hope to extend its experience to other hospitals and
insinuate its implementation to strengthen the health
service in the country.
What Case Mix Is

Refers to the Mix of Cases of a Hospital, the Range and Type of
Patients Treated

Case Mix Information can tell us How Much Money Hospitals Need
According to the Patients they Actually Treat

Case Mix is Hospital Final Output, Classified into Predetermined
Categories (DRGs)

Case Mix Information about Resource Use and Quality can be Used as
Standards for Hospitals to Compare Based on patient characteristics

Case Mix is a Tool - Case Mix Information Provides the Knowledge to
Critically Examine Patient Care and Manage Appropriately
Comparative data
What Case Mix Is Not
















A Method for Cutting Health Budgets - Case Mix
can Help Ensure that Available Funds are
Distributed Rationally
•
A Tool to Control Doctors - Case Mix can be used
to Compare the Kind of Treatment Doctors Give
Patients
•
A Method of Changing Hospital Work Practices Hospitals can use Information to Examine
Practices and Identify Where Changes Might be
Needed
•
A way of Removing Management of Health from
Doctors and Nurses - Case Mix Enables Doctors
and Nurses to Better Manage Health Care
CaseMix Analysis






The Ministry compares
The Regions
The Hospitals
The Departments
the Physicians...
...the Patients
NordDRG

The
Nordic
Medico-Statistical
Committee
(NOMESCO) of the Nordic Council of Ministers
charged in 1995 the WHO Collaborating Centre for
the Classification of Diseases in the Nordic
countries with the task of designing a DRG
system, possible to use after the introduction of
ICD-10 and NCSP.
NordDRG

The objective of the design project was to create a
patient classification system that is public domain,
with openly accessible grouping definitions, based
on the ICD-10 and NCSP, and easily maintainable
and possible to develop beyond DRGs, in order to
meet the requirements of Nordic clinical practice.

The project was divided into three phases
1). Conversion tables between ICD-10 and ICD-9-CM and
NSCP and ICD-9-CSP(classification of surgical procedures) ,
respectively, were produced and published
Secondly, standardised HCFA-like DRG Definitions were
created, directly using ICD-10 and NCSP codes
Thirdly, grouping software was designed both as a “Common
Nordic” version and as national versions, containing national
modifications of the ICD-10 and NCSP
The NordDRG Definitions and the NordDRG Grouper
(national versions) are the property of the national health
authorities. They are responsible for the national versions and
their distribution within their respective country
NordDRG



The Nordic Medico-Statistical Committee (NOMESCO) of the
Nordic Council of Ministers initiated in 1994 a project to create
a Nordic case-mix system to make it possible to compare
health care statistics in the Nordic countries. The case-mix
system was also aimed for planning, budgeting, management
and financing inpatient care at hospital.
The objective of the design project was to create a patient
classification system that is public domain, with openly
accessible grouping definitions, based on the ICD-10 and
NCSP (Nomesco Classification of Surgical Procedures). The
system has to be easily maintainable and possible to develop
beyond DRGs, in order to meet the requirements of Nordic
clinical practice. The system also had to derive from the logic in
HCFA-DRG version 12.0.
In 1996 the first version of NordDRG was developed. From
1997 the new system was in practice in Stockholm County
Council in Sweden and in some health care districts in Finland.
In 2002 all Nordic countries use NordDRG except Island
Current condition



Around 20 hospitals in Sweden have case-costing
systems for inpatient care in use (or 25% of the yearly
cases in Sweden). The Federation of Swedish County
Councils collects case-costing data from the hospitals
to a national case-costing database.
The National case-costing project has been running
since 1999. The project was ending in year 2002. Casecosting will continue as a part of the ordinary activity
at the Federation of Swedish County Councils.
Approximately 50% of the County Councils have local
case-costing projects. This will hopefully lead to more
cases in the case-costing database in the near future;
many new hospitals are already implementing casecosting systems. Case-costing systems are today noncompulsory in Sweden.
Case-costing systems for psychiatry, outpatient care
and primary care are also on the list for development. A
few Swedish hospitals already implemented case
costing for outpatient care
1980
The classification “Diagnosis Related Groups” )DRG( was established by
Professor Robert Fetter and Jon Thompson from Yale University to categories
patient scene in American hospital. The version that has been used contained
383-diagnosis group known as DRG, the first version using ICD-8 as “Grouping
Principal System”. The second version contained 467 DRG group, which was
created in line with ICD-9 and ICD-9-Cm for operation procedures.
1983
Health Care Financing Authority (HCFA) in USA used case-mix system to support
the health services under social scheme insurance that is Medicare and
Medicaid.
1990
Case mix system was introduced to Australia. The research over case-mix
system has been resembled by the health services authority in South Australia,
New South Wales University and the Royal Children’s Hospital in Melbourne.
After that the case-mix system has been broaden to all places in Australia.
1992
Case-mix system was introduced in Singapore and has been tried as payment
system in health service.
1994
Case-mix system was introduced in Thailand under the Thailand National
Scheme insurance.
1997
The research on case-mix system as a method of health care financing in
Malaysia was approved and given the budget under the IRPA Top-Down project
to UKM, UM, USM and Ministry Of Health Malaysia.
TYPE OF CASE-MIX SYSTEM



From the first version of DRG in 1983, some researcher
have modified the DRG for their used with changes made to
satisfy the disease pattern in their country.
All Patient Refined DRGS (APR-DRGS) are using the
patient sickness to ensure that the classification can only
detected the patient that really needed the more resources
causes by the chronic disease. Australia used their own
Case-mix system that is Australia National DRGS (ANDRG) since 1992. United Kingdom used Health Care
Resources Group (HRG), and Canada used Classification
Case-mix Group (CGM).
UKM hospital will be using the latest Case-mix system that
is IR-DRG (International Refined DRG) that contains 965
groups .This system is fundamental to ICD-10 for main
diagnosis and ICD-9CM for operation procedure. This IRDRG classification will be a principle to achieve the
establishment of Malaysia own Case-mix system in the
future. The classification contains all group age and almost
all-major operation that has been done in one hospital.
NordDRG weight list


The DRG-weight is a relative measure of care and
treatment costs for an average patient in a DRG. A
high weight indicates high cost. To get weight lists that
are validated and representative the calculation must
be based on a large database. The average cost for
all cases in the database have the state of DRGweight 1.0. The weight for each DRG is calculated by
dividing the average cost for each DRG with cost that
represents DRG-weight 1.0.
The DRG average cost is the basis for cost
comparability in the calculation of cost-weights.
Patients with a long length of stay or high cost may
have a disproportional influence on the average cost.
The method to exclude those cases from the database
is called trimming and the excluded cases are
representative
NordDRG weight list



called outliers. About five percent of the database
are technical defined as outliers. Trimming the
data is to improve the comparability of the data.
When weight lists are used in a reimbursement
system the outliers get paid separate. Limits for
outliers are specified in the weight list.
Annually CPK produce a national weight lists
based on the national case-costing database. All
hospitals in the case-costing database have
calculated the cost by the cost per case method.
The national weight lists are mainly used as a
reference list. There is a predominance of region
hospitals in the national case-costing database
why the cost weights are not absolutely
‫‪Australia‬‬
‫)‪AN-DRG( Australian National DRG‬اولين سيستم طبقه بندي‬
‫‪ DRG‬استراليا كه توسط ‪ 3M‬و ‪ common wealth‬بصورت مشترك ايجاد‬
‫شد ‪ .‬بين ‪ 1992‬و ‪ 1996‬نسخه هاي ‪ 1.0, 2.0, 2.1, 3.0 and 3.1‬ايجاد‬
‫شده است‬
‫‪ AR-DRG‬دومين سيستم طبقه بندي ‪ DRG‬استراليا كه از سال ‪ 1997‬ايجاد‬
‫شده ونسخه هاي ‪ 4.0 ، 3.2‬در سالهاي ‪ 1991-1998‬بر اساس كدهاي ‪ICD-‬‬
‫‪ 4.1 ،9-CM‬در سالهاي ‪ 1998-2000‬بر اساس اولين ويرايش ‪ICD-10-‬‬
‫‪ 4.2 ، AM‬از سال ‪ 2001‬بر اساس دومين ويرايش ‪، ICD-10-AM‬‬
‫تاكنون استفاده شده اند‪ .‬ساعات بيهوشي‪ ،‬تنفس مصنوعي و وضعيت بهداشت‬
‫رواني از جمله مواردي است كه در اين سيستم در نظر گرفته شده اند‪ .‬نسخه‬
‫‪ 4.2‬از ‪ MDC 23‬به همراه ‪ pre-MDC 8‬و ‪ error DRGs 7‬تشكيل شده‬
‫است‪ MDC .‬ها بر اساس يك سيستم بدني واحد يا اتيولوژي كه به يك تخصص‬
‫پزشكي خاص مربوط مي شود‪ ،‬ايجاد شده اند‪.‬‬
‫‪ Australian Commonwealth Medical Benefit Schedule :MBS‬در پرداخت‬
‫پزشكان استراليا استفاده مي شود‪.‬‬
‫‪Australia‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫متغيرهاي مورد استفاده براي گروه بندي ‪ AR-DRG‬عبارتند از‪:‬‬
‫تشخيص ها (اصلي‪ ،‬ساير)‬
‫اقدامات‬
‫جنس‬
‫سن‬
‫نوع پايان وقايع[‪]1‬‬
‫مدت اقامت‬
‫روزهاي ترك بيمارستان (ترخيص موقت)‬
‫وزن هنگام پذيرش(براي كودكان زير يكسال)‬
‫وضعيت بهداشت رواني‬
‫ساعات تهويه مكانيكي[‪]2‬‬
‫وضعيت هايي كه بيمار در يك روز پذيرش و در همان روز ترخيص مي شود‪.‬‬
‫‪‬‬
‫‪[1] Events end type‬‬
‫‪]2[ Hours of mechanical ventilation‬‬
‫‪‬‬
AR-DRG V4.2:
Germany

G-DRG - Diagnosis Related Groups

ICD-10 and OPS-301 Germany

The recent German Health Reform or
“Gesundheitsreform 2000” will introduce a German
Diagnosis Related Group (G-DRG) system in the hospital
sector planned to be fully operational by 2003. Up to then
run the adaptation time of the German health system on
DRG-System. This reform will change the current hospital
financing system on the basics of Australian DRGSystem. The Departments for Psychiatry are excluded
from DRG-financing. Hospitals are using ICD-10 Version
2.0 for Diagnosis-Coding and OPS-301 for ProcedureCoding (12.06.2001)
‫‪canada‬‬
‫‪‬‬
‫در كانادا گروه هاي كيس ميكس )‪ (CMG‬بر اساس معتبر ترين‬
‫تشخيص‪ ،‬كه در زمان ترخيص بيشترين طول اقامت را به خود‬
‫اختصاص مي دهد‪ ،‬ايجاد شده اند‪ .‬گروه هاي كيس ميكس‪ ،‬مرتبا‬
‫بر اساس نياز كاربران‪ ،‬روزآمد مي شوند‪ .‬مثال پيچيدگي بيماري و‬
‫سن بيمار اخيرا در گروهها لحاظ شده است‪ .‬سن بيمار از اين‬
‫جهت مهم است كه بيماران كم سن و سال و افراد پير و مسن اغلب‬
‫به تدابير درماني بيشتري نياز دارند‪.‬‬
‫)‪America(case mix classifications‬‬
‫‪Yale refinement DRGs‬‬
‫‪‬‬
‫‪:‬بر اساس مطالعة پيامد هاي بيماري هاي همزمان و عوارض بهره وري از منابع‬
‫بيمارستاني تنظيم شده است‪ .‬همچنين تشخيص هاي ثانويه مرتبط با برخي تشخيص هاي‬
‫اصلي مورد توجه قرار گرفته اند‪.‬‬
‫‪New York DRGs‬‬
‫‪‬‬
‫‪‬‬
‫يكپارچه سازي فعاليت هايي كه توسط مديكير انتخاب نمي شوند‪ ،‬ولي براي سايربيماران‬
‫انجام مي شوند اين فعاليت ها براي افراد مسن انجام نمي شوند‪ .‬مثل ايدز‪ ،‬جراحت ها‪،‬‬
‫بيماري هاي نوزادان ‪ ،‬اعتياد دارويي و‪...‬‬
‫‪New York CSI DRGs‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪ DRGs‬نمايه شدت نيويورك‪ :‬توسط پژوهشگران موسسة پزشكي جانز هاپكينز در‬
‫اوايل دهة ‪ 1980‬ايجاد شد و به شدت بيماري در ‪ DRG‬توجه شد‪.‬هر تشخيص اصلي يا‬
‫ثانويه براساس ‪ 4‬معيار شدت بندي شد‪ :‬سبك‪ ،‬متوسط‪ ،‬شديد‪ ،‬تهديد كنندة زندگي و زير‬
‫گرو ه هايي براي هر يك در نظر گرفته شد‪.‬‬
‫)‪America(case mix classifications‬‬
‫)‪Pediatric Modified DRGs (PM-DRGs‬‬
‫‪‬‬
‫‪‬‬
‫طي سالهاي ‪ 1984 -1987‬توسط انجمن ملي بيمارستان هاي كودكان و موسسات‬
‫مربوطه[‪)] (NACHRI1‬براي بيماران كمتر از ‪ 17‬سال ايجاد شد علت اصلي‬
‫ايجاد اين سيستم اين بود كه ‪ DRG‬اصلي ‪ ،‬وضعيت هاي پرهزينه و پيچيده كودكان‬
‫را كه اغلب در بيمارستان هاي تخصصي درمان مي شدند به خوبي منعكس نمي‬
‫كرد‪ .‬بنابراين در ارائه منابع كافي براي كودكاني كه نياز به مراقبت پزشكي خاص‬
‫داشتند و براي سازمان هايي كه اين مراقبت ها را ارائه مي كردند ‪ ،‬مشكالتي ايجاد‬
‫مي شد‪ .‬به اين ترتيب به منظور رفع اين مشكالت حدود صد ‪ DRG‬به ‪DRG‬هاي‬
‫قبلي افزوده شد‪.‬در واقع اين سيستم مكمل ‪ DRG‬است نه بخشي از آن‪.‬‬
LTC-DRGs
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long-term care diagnosis- related groups
Cases are classified into LTC-DRGs for payment
based on the following six data elements:
(1) Principal diagnosis.
(2) Up to eight additional diagnoses.
(3) Up to six procedures performed.
(4) Age.
(5) Sex.
(6) Discharge status of the patient
‫‪England‬‬
‫‪‬‬
‫در انگلستان ‪ ،‬در سال ‪ ،1984‬اولين كنفرانس بين المللي ‪ DRG‬در لندن‬
‫برگزار شد‪.‬در اين كنفرانس انجمن ]‪PCS/E [1‬با شركت نمايندگاني از ‪6‬‬
‫كشور اروپاي غربي تشكيل شد‪ .‬از آن زمان تاكنون كنفرانس ساالنه در‬
‫كشورهاي مختلف اروپايي و استراليا تشكيل شده است‪.‬موضوع مورد بحث‬
‫كنفرانس مفاهيم جديد در عرصه كيس ميكس است و فصلنامه رايگاني نيز‬
‫در اين زمينه منتشر مي كند‪ .‬امروزه اين انجمن با بيش از ‪ 50‬كشور‬
‫مختلف از سراسر دنيا ارتباط دارد‪ .‬در كنفرانس ‪ PCS/E‬كه در سال‬
‫‪ 1999‬در ادنس [‪ ]2‬برگزار شد‪ 3M ،‬سيستم ]‪IAP-DRG[3‬را معرفي‬
‫كرد كه نسخه خالصه شده آن نيز وجود دارد كه به جاي ‪ 4‬سطح داراي ‪3‬‬
‫سطح ‪ CC‬بوده و در مجموع ‪ 1046‬گروه دارد‪.‬‬
‫‪‬‬
‫‪‬‬
‫‪[1] Patient classification systems/Europe‬‬
‫‪]2[ Odense‬‬
‫[‪International All Patient Diagnosis Related Groups]3‬‬
‫‪‬‬
‫‪France‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪ DRG‬در دهة ‪ 1980‬به كشور اورده شد‪.‬‬
‫‪ DRG‬در فرانسه ‪]1[ HGP‬نام گرفت‪ .‬با بهره گيري از‪ ،HGP‬از طريق تحليل‬
‫انحراف معيار ها‪ ،‬گام موثري در مديريت مالي برداشته شده است‪ .‬اقتصاد دانان‬
‫فرانسوي عالقمند بودند با استفاده از يك مرجع خارجي از وضعيت نسبي بيمارستان ها‬
‫آگاه شوند‪ .‬از سال ‪ ،1991‬راهنماي استفاده از ‪ HGP‬در زمينة پزشكي سازي سيستم‬
‫اطالعاتي (‪ ]2[)MIS‬ايجاد شد‪ .‬هدف رسيدن به يك پرداخت آينده نگر نبود‪ ،‬بلكه پايش و‬
‫تلفيق اختصاص يك بودجة سراسري به بيمارستان هاي عمومي بود‪ .‬پس از مذاكره ميان‬
‫وزارت بهداشت و وزارت بودجة فرانسه‪ ،‬ميزان عمومي برآمد هاي خاص در سطح ملي‬
‫مشخص شد‪ .‬در سطح محلي‪ ،‬بودجة ساليانه برابر است با بودجة قبلي ضربدر ميزان‬
‫تورم‪ .‬در اين اقدام مالي‪ ،‬ضرر و زيان ها و نوسانات احتمالي به علت سرمايه گذاري‬
‫هاي محلي و همچنين افزايش يا كاهش فعاليت بيمارستان ناديده گرفته مي شود‬
‫در مقايسه با ‪ ،DRG‬شمارة گروه ها تغيير كرده است‪ .‬برخي گروه ها اضافه شدند‪،‬‬
‫درحاليكه برخي از سيستم خارج شدند‪ ،‬همچنين تعدادي از تشخيص ها از يك ردة اصلي‬
‫به ردة ديگر منتقل شده اند‪.‬‬
‫‪[1] Homogeneous groups of patients‬‬
‫‪]2[Medicalisation of the Information System‬‬
‫‪‬‬
Other countries
Thailand
Taiwan
Indonesia
Denmark
Finland
Italy
Malaysia
Singapore
‫ايران‬
‫در ايران اين نوع روش پرداخت بکار گرفته مي شود و نظام طبقه بندي اي که به‬
‫عنوان پايه و اساس جهت بکارگيري روش پرداخت موردي استفاده مي شود نظامي با‬
‫عنوان نظام" گلوبال" است‪ .‬در اين نظام‪ ،‬بيماران بر طبق ‪ 60‬مورد از اعمال جراحي‬
‫شايع طبقه بندي مي گردند‪ .‬نظام" گلوبال" در مقايسه با نظام "گروه هاي مرتبط‬
‫تشخيصي" داراي نواقص بسياري است‪ .‬نظام" گلوبال"‪ ،‬موارد بيماري را شامل نشده‬
‫و تنها در مورد اعمال جراحي و تنها در ‪ 60‬مورد کاربرد دارد‪ .‬طبقات تشخيصي‬
‫اصلي‪ ،‬گروه های مرتبط تشخيصی پايه که در نظام هاي "گروه هاي مرتبط‬
‫تشخيصي" بطور جامع و کامل در نظر گرفته شده است در نظام " گلوبال" وجود‬
‫ندارد‪ .‬همچنين طبقاتي جهت اطالعات غيرمعتبر و متناقض‪ ،‬و وضعيت ترخيص‬
‫بيمار در نظر گرفته نشده است‪ .‬متغيرهاي سن‪ ،‬جنس‪ ،‬وجود يا عدم وجود عوارض و‬
‫بيماري هاي همراه‪ ،‬سطح خاص عوارض و بيماري هاي همراه‪ ،‬وزن زمان تولد‪/‬‬
‫ايران‬
‫پذيرش در نوزادان وجود نداشته و شدت بيماري و يا سطح پيچيدگي‬
‫کلينيکي بيمار‪ ،‬و نيز خطرمرگ را نمي توان با توجه به اين نظام تعيين‬
‫نمود ‪ .‬در نظام هاي "گروه هاي مرتبط تشخيصي" به هر"گروه"‪ ،‬کدي‬
‫تعلق مي گيرد که با کدهاي طبقه بندي بين المللي بيماري ها مرتبط و‬
‫هماهنگ است‪ ،‬اما در نظام " گلوبال" کدگذاري انجام نمي شود‪ .‬از‬
‫طرفي ديگر عامل وزن نسبي يا وزن هزينه اي‪ ،‬که در محاسبه هزينه‬
‫بيمار با توجه به نظام "گروه های مرتبط تشخيصي" جهت هر گروه‪ ،‬به‬
‫طور جداگانه تعيين مي شود در نظام " گلوبال" درنظر گرفته نشده‬
‫است‪ .‬بدين ترتيب مي توان اظهار داشت نظام " گلوبال" در مقايسه با‬
‫نظام "گروه های مرتبط تشخيصي" داراي کمبود ها و نواقصي است ‪.‬‬