Mastering MS-DRG Assignments to Enhance Reimbursements

Mastering MS-DRG Assignments to Enhance Reimbursements

Executives of hospital management often overlook medical coding as a contributing factor to the revenue cycle – but it’s a crucial link between earning well-deserved reimbursements from the services performed. One such revenue-defining coding system is the Medicare Severity Diagnosis Related Group (MS-DRG), which utilizes ICD-10 diagnosis and procedure codes, and other factors, such as age, sex, and discharge disposition, to facilitate payment for Inpatient services. In this introduction to MS-DRG assignments, we’ll explore examples of DRGs and introduce invaluable resources for selecting the correct DRG, including a DRG list and DRG assignment software.

What is Medicare Severity Diagnosis Related Group (MS-DRG) Coding?

MS-DRG is a sophisticated classification system that holds the power to categorize patients and their medical cases based on clinical characteristics and the resources required for their care (CMS, 2023). Each patient’s case is assigned a specific DRG, encapsulating diagnoses, procedures, age, sex, MCCs, CCs, and other relevant factors. These codes effectively communicate the complexity and intensity of services provided, determining reimbursement levels for hospital stays. Introduced by the Centers for Medicare and Medicaid Services (CMS), this system streamlines the payment process for Inpatient services.

It serves as a universal language, allowing healthcare providers to effectively communicate the complexity and intensity of services rendered. By assigning specific DRGs to patient cases, hospitals can accurately capture the intricacies of each scenario, leading to fair reimbursement and improved financial outcomes.

Accurate DRG assignment plays a pivotal role in directly impacting a hospital’s or facility’s reimbursements and revenue cycle. Accurate and appropriate DRG assignment ensures that the severity and complexity of each patient case are effectively communicated, leading to proper reimbursement for the resources invested in their care. By assigning the correct DRG, hospitals can optimize their revenue potential by capturing the true value of the services provided.

Additionally, accurate DRG assignment helps healthcare organizations navigate complex payment structures and regulatory guidelines, reducing the risk of undercoding or overcoding, which can result in financial penalties or revenue loss. A streamlined and efficient revenue cycle relies heavily on accurate DRG assignment, ensuring that hospitals receive fair and adequate reimbursements for the care they deliver while maintaining financial stability and sustainability.

DRG Examples

To grasp the practical application of DRG assignments, let’s explore some examples.

Patient admitted with the principal diagnosis of acute myocardial infarction is impacted when a percutaneous cardiovascular procedure is performed with drug-eluting or non-drug eluting stents or arteries.

DRG 246 PERCUTANEOUS CARDIOVASCULAR PROCEDURE WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS
DRG 247 PERCUTANEOUS CARDIOVASCULAR PROCEDURE WITH DRUG-ELUTING STENT WITHOUT MCC
DRG 248 PERCUTANEOUS CARDIOVASCULAR PROCEDURE WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS
DRG 249 PERCUTANEOUS CARDIOVASCULAR PROCEDURE WITH NON-DRUG-ELUTING STENT WITHOUT MCC

MDC 05 Disease and Disorders of the Circulatory System

Percutaneous Cardiovascular Procedures with Coronary Artery/Stent Decision Tree

Patient admitted with the principal diagnosis of acute myocardial infarction is impacted when the patient has a major complication or comorbidity (MCC) or complication and comorbidity (CC) or not and whether the patient was discharged alive or expired.

DRG 280 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC
DRG 281 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC
DRG 282 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC
DRG 283 ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC
DRG 284 ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC
DRG 285 ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC

MDC 05 Disease and Disorders of the Circulatory System

Acute Myocardial Infarction and Principal Diagnosis Decision Tree

Patient admitted with the principal diagnosis of pneumonia is impacted when the patient has a major complication or comorbidity (MCC) or complication and comorbidity.

DRG 193 SIMPLE PNEUMONIA AND PLEURISY WITH MCC
DRG 194 SIMPLE PNEUMONIA AND PLEURISY WITH CC
DRG 195 SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

MDC 04 Diseases and Disorder of the Respiratory System

Simple Pneumonia as the Principal Diagnosis Decision Tree

DRG Resources

Here are several DRG resources to assist with appropriate assignment:

MS-DRG List: This comprehensive DRG list from CMS includes a vast range of codes representing various medical cases, diagnoses, procedures, and patient profiles. This list enables healthcare providers to accurately assign the most suitable DRG, streamlining the reimbursement process and optimizing financial outcomes.

MS-DRG Grouper Software: An invaluable tool in correctly assigning DRGs is the MS-DRG Grouper software. The software calculates payments to cover the costs of an Inpatient encounter. The coder enters the ICD-10-CM/PCS codes into the software, and it calculates the MS-DRG based on those codes the user has selected. The MS-DRG payment equals the MS-DRG relative weight multiplied by the hospital blended rate.

Utilize Our Coding Support Services to Assign DRGs & Optimize Revenue

YES offers expert coding support services for DRG assignment, designed to streamline providers’ processes, ensure compliance, and maximize revenue potential. Here’s why you should choose our services:

• Expertise and Experience: Our highly skilled team of certified coding professionals possesses extensive knowledge and experience in coding and assigning DRGs. We remain current with the latest industry regulations and guidelines, guaranteeing accurate and comprehensive coding to maximize reimbursements.
• Compliance and Audit Readiness: We recognize the importance of compliance in healthcare. Our services ensure that your coding practices align with regulatory guidelines, safeguarding your organization from penalties and preparing you for any compliance audits.
• Revenue Optimization: By leveraging our DRG assignment and coding support services, you unlock the full revenue potential of your organization. Utilizing our customized trending reports, we identify areas for improvement, minimize coding errors, and provide actionable insights to enhance financial performance.

Mastering DRG assignment is essential for hospitals and healthcare organizations to achieve optimal reimbursements and operational efficiency. Contact us today to discuss how our coding support services can elevate your coding practices and drive superior outcomes.