It should be noted that patients with a principal

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It should be noted that patients with a principal diagnosis not typically considered a reason for hospitalization are not assigned to DRG 469. For example, ICD-9-CM code V503, ear piercing, is assigned to DRG 467 and not to DRG 469. Patients are assigned to DRG 470 if certain types of medical record errors which may affect DRG assignment are present. Patients with an invalid or nonexistent ICD-9-CM code as principal diag- nosis will be assigned to DRG 470. Patients will also be assigned to DRG 470 if their age, sex, or discharge status is both invalid and necessary for DRG assignment. For example, if a patient with a principal diagnosis of a valvular disorder has a non-numeric age or has an age coded greater than 124 (age greater than 124 is considered invalid), the assignment will be to DRG 470 since patients with valvular disorders will be assigned to different DRGs depending on their age. On the other hand, if the same patient had a principal diagnosis of hypertension, the assignment will not be to DRG 470 since age is not used in the determination of the DRG for hypertensive patients. The actual process of forming the DRGs was highly iterative, involving a combination of statistical results from test data with clinical judgment. At any point during the definition of the DRGs, there would often be several patient characteristics which appeared important for understanding the impact on hospital resources. The selection of the patient characteristics to be used, and the order in which they would be used, was a complex task with many factors examined and weighed simultaneously. The end result of this process was the formation of a comprehensive set of DRGs that described all patients treated in acute care hospitals.
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11 Revisions of the DRGs for Medicare The DRG definitions originally developed at Yale were intended to describe all the types of patients seen in an acute care hospital. Thus, the DRGs encompassed both the elderly patient population as well as the newborn, pediatric, and adult populations. With the implementation of the Medicare prospective payment system (PPS) in October, 1983, the responsibility for the main- tenance and modification of the DRG definitions became the responsibility of the Centers for Medicare and Medicaid Services (CMS). Since the inception of the Medicare PPS, the DRG defi- nitions have been updated annually. Under contract with the Centers for Medicare and Medicaid Services, 3M Health Information Systems has performed all revisions of the DRG definitions, related software, and documentation. The focus of all DRG modifications instituted by CMS has been on problems relating to the elderly population. For example, limitations in the DRGs relating to the newborn and pediatric populations have never been addressed by the CMS modifications.
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  • Fall '18
  • Diagnosis-related group, DRGs

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