In assigning the drg the grouper software employs

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In assigning the DRG, the Grouper software employs logic in a decision tree that examines conditions that apply to the individual patient and that episode of care. The decision tree (logic) is applied to patient demographic and morbidity information. Importantly, the Principal medical diagnosis is the single greatest influence in assigning the DRG. Surgical codes and secondary diagnosis are considered in refining the DRG assignment and in particular, to recognise 'Complicating Conditions (CC)". The Decision Tree PRINCIPAL DIAGNOSIS (PDx) MAJOR DIAGNOSTIC CATEGORY (23 GROUPS) SURGICAL PROCEDURE NO YES MEDICAL SEPARATION SURGICAL SEPARATION PRINCIPAL DIAGNOSIS Neoplasms, Specific conditions, Symptoms, other TYPE OF SURGERY Major, minor, other unrelated diagnoses COMPLICATIONS, CO-MORBIDITY OR AGE SPLIT (CCL and PCCL) AR-DRG Figure Four – The DRG Decision Tree
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An Introduction to DRG's TC Health Administration © 9 Variables affecting DRG Assignment These include: head2right Principal diagnosis; head2right Procedure codes head2right Secondary Codes; head2right Age and Gender; head2right Birth Weight (neonates); head2right Discharge Status (to Home, to another Hospital, Died etc.) The Principal Diagnosis Is the principal determinant of the DRG result. The doctor who is responsible for the treatment of the patient is the person who determines the principal diagnosis The Principal Diagnosis (see Figure Four) is used to determine the Major Diagnostic Category (MDC). These categories correspond to the main body organ systems. There are 23 Major Diagnostic Categories. Definitions of the principal diagnosis vary in Australia. In some States it is the "Principal reason for admission to Hospital". Elsewhere it can be "The most resource intensive diagnosis". Interpretation of "Principal Diagnosis" can make a significant difference to the amount of payment reimbursement. If there is a choice of principal diagnosis then the Hospital can gain by choosing the diagnosis that produces the higher payment (Optimising the DRG). The AR-DRG grouping process generally involves four stages – refer Figure Three. 1. The Principal diagnosis is used to assign the episode of care to one of the MDC's. There are some specific exceptions where a separate DRG Classification is assigned. These exceptions include: head2right Age less than 29 days; head2right Principal diagnosis which is a specific neonatal disorder; head2right Principal diagnosis of multiple trauma; head2right Liver transplant; head2right Bone marrow transplant; head2right Tracheotomy procedure; head2right Principal or secondary diagnosis of HIV. 2. Medical or surgical separation according to whether a significant operating room procedure has been performed. Not all surgery is considered to be significant.
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  • Fall '18
  • Diagnosis-related group, DRG

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