59 background and explanation of approach for

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59 BACKGROUND AND EXPLANATION OF APPROACH FOR REROUTING LOGIC IN VERSION 20.0 APR-DRGS Background The basic organizing approach to classification in the APR-DRG system is to first assign a patient to a Major Diagnostic Group (MDC), based upon principal diagnosis, and then to a specific APR-DRG category based upon principal diagnosis (if medical) or operating room procedure (if surgical). This works well in the vast majority of cases to categorize the patient into an MDC and APR-DRG that most aptly describes the reason for the hospitalization. There are several different kinds of situations, however, where the principal diagnosis (PDX) based approach, as the starting point for establishing the MDC and APR-DRG, needs to be sup- plemented by additional information and logic to yield the most useful classification. One situation is where there is an overwhelming consideration that should take priority. This is handled by a Pre-MDC Assignment Logic, which is described in detail in chapter 2 of the APR-DRG Definitions Manual. The Pre-MDC Assignment Logic handles assignment to the major organ transplant APR-DRGs, the neonatal MDC (based on age), the two tracheostomy APR-DRGs, the Multiple Significant Trauma MDC, and the HIV MDC. The other situation where the PDX-based starting point for APR-DRG classification needs to be supplemented by additional information and logic, is where the PDX is overly broad or the sequencing of PDX and SDX is unclear, or in some instances the OR procedure is unclear. These are handled through what is referred to as APR-DRG “rerouting logic.” This is the logic that con- siders secondary diagnoses, procedures and sometimes age, most often in conjunction with the PDX, to clarify the reason for the hospitalization. The rerouting logic either reassigns the patient to a new APR-DRG within the same MDC (Within MDC Rerouting) or to a new MDC and APR-DRG (Across MDC Rerouting). These situations are not unique to the APR-DRG classification system. They represent ambigu- ities that confront any DRG classification system. What is unique to the APR-DRG classification system is the rerouting logic developed to assign these patients to the most appropriate and use- ful category. Version 20.0 of the APR-DRG system incorporates a number of updates to the previously existing Within MDC Reroutings and introduces for the first time, Across MDC Rerout- ings. Following is a description of the need for APR-DRG rerouting logic, an explanation of the method- ology for the APR-DRG reroutings, and a set of detailed examples of Within MDC Reroutings and Across MDC Reroutings. Attached is a table summarizing all of the APR-DRG reroutings. For code level specifications, please see the full Version 20.0 APR-DRG Definitions Manual.
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  • Fall '18
  • Diagnosis-related group, DRGs

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