principal diagnosis
→ the condition established after study to be chiefly responsible for admission to the
hospital
complication
→ an additional diagnosis that arises after the beginning of hospital observation and
modifies the course of the patient's illness or medical care required
co...
MS-DRG QUESTIONS AND ANSWERS
2024/2025
principal diagnosis
→ the condition established after study to be chiefly responsible for admission to the
hospital
complication
→ an additional diagnosis that arises after the beginning of hospital observation and
modifies the course of the patient's illness or medical care required
comorbidity
→ a preexisting condition that will likely cause an increase in the patient's length of stay
principal procedure
→ performed for definitive treatment (rather than diagnostic or exploratory purposes), or
when it is necessary to take care of a complication.
significant procedure
→ - surgical in nature
→ - carries a procedural risk
→ - carries an anesthetic risk
→ - requires specialized training
What is an MS-DRG?
→ An inpatient classification system designed to categorize patients who are medically
related with respect to diagnoses and treatment and who are statistically similar in
their lengths of stay. Each DRG has a preset reimbursement amount.
Acute care hospitals receive Medicare IPPS payments on a per discharge basis for Medicare
beneficiaries -- one payment per one inpatient hospital stay
→
All outpatient diagnostic services and admission-related therapeutic services provided by the
same hospital on the day of the patient's admission or within three days preceding the date of
inpatient admission must be included on the inpatient hospital claim to Medicare and is paid
as part of the MS-DRG payment. No separate payment is made for these outpatient services.
→
What is relative weight?
→ The average resources required to care for cases in the particular DRG relative to the
national average of resources required to treat all Medicare cases.
What is the average relative weight?
→ 1.00000. Thus, cases with an MS-DRG of 2.0000, require twice as many resources as
the average Medicare case.
What is the hospital's payment rate?
→ it's based on a regional adjusted standardized amount that considers the type of
hospital and a wage index
DRG Relative Weight X Hospital Base Rate = Hospital Payment
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