Lecture Icd 10

Baruch College/Mount Sinai
School of Medicine
Program in Health Care
Administration and Policy

Medical Record Coding and DRGs

BUS9100
Lecture 10
Raymond R. Arons, Dr. P.H, M.P.H
February 9, 2010

Lecture 10 2

Baruch College/Mount Sinai School of Medicine
Program In Health Care Administration and Policy
BUS 9100: The Social and Governmental Environment
of the Business of Health Care

Lecture 10-February 9, 2010

Revenues, Medical Record Coding and DRGs

Raymond R. Arons, Dr. P.H, M.P.H

http://www.cms.hhs.gov/TheChartSeries/03_Health_Care_Facts_Figures.asp#TopOfPage

Section 10.0
The Hospital Revenue Cycle

Copyright © 2010 Raymond R. Arons, Teaneck, NJ, USA

Lecture 10 3

INPATIENT REVENUE CYCLE
Patient Demographics
Admitted Insurance, Other
To Hospital Data Captured

Diagnoses (Dx.), Patient
Procedures (Pr.), Discharged
in Medical Record

Coders take the Dx. Bill is submitted
and Pr. Convert to to Insurance
ICD codes for billing Company
For Payment $$$
3

Revenue Cycle Obstacles to Payment
Bill is not complete and is bounced by Insurance
Company
– Insurance ID incorrect.
– Other, missing elements such as secondary payer,
age sex, race, ethnicity, procedure dates etc.
– Submission is not within the time limits.
– Other factors such as denials etc,
– Admitted within 30 days of discharge.
– Never received claim.
– Errors in medical record coding.

4


Lecture 10 4

Section 10.1
International Classification of
Diseases Coding Methods

Coding Methods Currently in Use
International Classification of Diseases - ICD-9-CM
– Coding of Inpatient Discharges
International Classification of Diseases - ICD-10-CM
– Mandated for 2013 but used as of 12/30/09
Diagnosis-related Groupings (DRGs)
– Hospital reimbursement -Medicare
– Hospital reimbursement -Non Medicare
Physician Current Procedure Terminology (CPT)
– Physicians for procedures performed
Common Procedure Coding System (HCPCS)
– Used by vendors of equipment and services

6


Lecture 10 5

International Classification of Diseases
(ICD-9-CM)
History
Definitions
Classification of Diseases Groupings
Disease Coding
Procedure Grouping
Procedure Coding
Other Areas such as V codes, E codes

7

ICD History
Statistical classification of diseases date back to the
eighteenth century with a primary focus upon the
causes of death
The Sixth Revision, in 1948 expanded to include non-
fatal diseases. In 1950 the US Public Health Service
and the Veterans Administration began independent
tests of ICD-6 for hospital indexing purposes.
In 1951 the Presbyterian Hospital in New York City
adopted the ICD-6th Revision with some modifications
for use in its record department (HCFA,1980)

8


Lecture 10 6

ICD History
The Ninth revision in 1975 in Geneva included
procedures in medicine and of impairments, and
handicaps. ICD-9-CM became effective in January
1979 and is currently up to its latest revision to keep
up with new technologies, procedures, and diseases.
Over the past century, ICD was under the control of
WHO, The Commission on Professional Hospital
Activity and currently the Health Care Financing
Administration (HCFA), and Centers for Medicare and
Medicaid (CMS)
ICD-10-CM was released in 1999 and will be required
for physician and hospital use in 2013 and currently is
optional as of December 2009

9

Definitions
A classification of disease may be defined as a system
of categories to which morbid entities are assigned
according to established criteria.

A Statistical classification of diseases must
encompass the entire range of morbid conditions
within a manageable number of categories (ICD-10,
WHO,1992)

10


Lecture 10 7

Examples of I9 Codes
Infectious and Parasitic Diseases (000-139)
042 Human immunodeficiency virus (HIV)
090.0 Early congenital syphilis,symptomatic
Neoplasms (140-239)
162.2 Malignant neoplasm of the main bronchus
191.1 Malignant neoplasm of the fontal lobe
Endocrine,Nutritional and Metabolic Diseases and
Immunity Disorders (240-319)
250.1 Diabetes mellitus with ketoacidosis
278.01 Morbid obesity

11 continued...

Blood and Blood-Forming Organs (280-289)
282.6 Sickle-cell anemia
285.9 Anemia, unspecified
Mental Disorders (290-319)
295.4 Acute schizophrenic episode
296.3 Major depressive disorders
Nervous System and Sense Organs (320-389)
332.0 Parkinson’s disease with paralysis
agitans
362.0 Diabetic retinopathy

12 continued...


Lecture 10 8

Diseases of the Circulatory System (390-459)
410.1 Acute myocardial infarction of anterolateral
wall
414.0 Heart Failure
Diseases of the Respiratory System (460-519)
492.0 Emphysema bleb
493.9 Asthma, unspecified
Diseases of the Digestive System (520-579)
540 Acute appendicitis with generalized peritonitis
550 Inguinal hernia, with gangrene

13 continued...

Diseases of the Genitournary System (580-629)
592.0 Calculus of the kidney
600 Hyperplasia of prostate
Complications of Pregnancy and Childbirth and the
Puerperium (630-676)
633 Ectopic pregnancy
634 Spontaneous abortion
Diseases of the Skin and Subcutaneous Tissue(680-
709)
684 Impetigo
697.0 Lichen planus

14 continued...


Lecture 10 9

Congenital Anomalies (740-759)
734.61 Flat foot congenital
749.00 Clef palate, unspecified
Certain Conditions Originating in the Perinatal Period
(760-779)
760.0 Maternal hypertensive disorder
762.4 Prolapsed cord
Symptoms, Signs and Ill-defined Conditions (780-799)
780.6 Fever
780.1 Hallucinations

15 continued...

Diseases of the Musculoskeletal System and
Connective Tissue (710-739)
714.0 Rheumatoid arthritis
722 Intervertebral disc disorder
733.1 Pathologic fracture

Injury and Poisoning (800-999)
800.1 Open fracture of clavicle
952.01 C1/C4 level with complete lesion of spinal
cord

16 continued...


Lecture 10 10

Supplementary Classification of Factors Influencing
Health Status and Contact with Health Services (V01-
V82)
V30.00 Single live born vaginal delivery in hospital
V60.3 Person living alone

Supplementary Classification of External Causes of
Injury and Poisoning (E800-E999)
E813 Motor Vehicle traffic accident highway
collision
E800 Railway accident involving collision with train

17 continued...

Examples of I9 Procedure Codes
Operations of the Nervous System (01-05)
01.0 Cranial puncture
01.2 Craniotomy and craniectomy
03.01 Removal of foreign body from spinal canal
Operations on the Endocrine System (06-07)
06.01 Aspiration of thyroid
07.8 Thymectomy
Operations on the Eye (08-16)
16.3 Evisceration of eyeball
16.82 Repair of wound of orbit

18 continued...


Lecture 10 11

I9 Procedure Codes
Operations of the Ear (18-20)
18.0 Incision of External Ear
20.0 Myringotomy
20.96 Implantation or replacement of cochlear
prosthetic device
Operations on the Nose,Mouth and Pharynx (21-29)
21.0 Control of epistaxis
21.7 Reduction of a Nasal Fracture
Operations on the Respiratory System (30-34)
32.4 Lobectomy of lung
33.5 Lung transplant

19 continued...

I9 Procedure Codes
Operations on the Cardiovascular System (35-39)
35.2 Replacement of Heart Valve
37.5 Heart Transplant
38.5 Ligation and stripping of varicose veins
Operations on the Hemic and Lymphatic System (40-41)
40.11 Biopsy of lymphatic structure
41.01 Autologous bone marrow transplant
Operations on the Digestive System (42-54)
42.42 Total esophagectomy
47.0 Appendectomy

20 continued...


Lecture 10 12

I9 Procedure Codes
Operations on the Urinary System (55-59)
55.5 Complete nephrectomy
55.6 Kidney Transplant
Operations on Male Genital Organs (60-64)
60.2 Transurethral prostatectomy
64.5 Operation for sex transformation, NEC
Operations on Female Genital Organs (65-71)
68.6 Radical abdominal hysterectomy
69.92 Artificial insemination

21 continued...

I9 Procedure Codes
Obstetrical Procedures (72-75)
74.0 Classical cesarean section
72.31 High forceps operation with episiotomy
Operations on Musculoskeletal System (76-84)
79.85 Open reduction of dislocation of hip
81.51 Total hip replacement
Operations on the Integumentary System(85-86)
85.23 Subtotal mastectomy
85.94 Removal of implant of breast

22 continued...


Lecture 10 13

I9 Procedure Codes
Miscellaneous Diagnostic and Therapeutic Procedures
(87-99)
87.1 Other x-ray of face, head and neck
88.4 Arteriography using contract materials
88.93 Magnetic resonance imaging of spinal
canal
89.4 Cardiac stress tests and pacemaker checks
94.4 Psychotherapy and counseling
99.92 Other acupuncture

23 continued...

Usage of I9 Coding Systems
All discharges from hospitals, visits to physician
offices, ambulatory care centers, and other sites of the
delivery of care require and ICD-9-CM code that
reflects the various diseases that were treated and
procedures performed.
All bills to third party agencies, Medicare, Medicaid,
Blue Cross and other payors require diseases and
procedures that were written in charts to be coded by
staff prior to being submitted for payment. As of 2013
the ICD-10-CM will be required.

24


Lecture 10 14

A Sample of ECODES (Accidents)
E8000 RR COLLISION NOS-EMPLOY
E8001 RR COLL NOS-PASSENGER
E8002 RR COLL NOS-PEDESTRIAN
E8003 RR COLL NOS-PED CYCLIST
E8008 RR COLL NOS-PERSON NEC
E8009 RR COLL NOS-PERSON NOS
E8010 RR COLL W OTH OBJ-EMPLOY
E8011 RR COLL W OTH OBJ-PASNGR
E8012 RR COLL W OTH OBJ-PEDEST
E8013 RR COLL W OTH OBJ-CYCL
E8018 RR COL W OTH OBJ-PER NEC
E8019 RR COL W OTH OBJ-PER NOS

25

A Sample of VCODES
V3000 SINGLE LB IN-HOSP W/O CS
V3001 SINGLE LB IN-HOSP W CS
V301 SINGL LIVEBRN-BEFORE ADM
V302 SINGLE LIVEBORN-NONHOSP
V3100 TWIN-MATE LB-HOSP W/O CS
V3101 TWIN-MATE LB-IN HOS W CS
V311 TWIN, MATE LB-BEFORE ADM
V312 TWIN, MATE LB-NONHOSP
V3200 TWIN-MATE SB-HOSP W/O CS
V3201 TWIN-MATE SB-HOSP W CS
V321 TWIN, MATE SB-BEFORE ADM
V322 TWIN, MATE SB-NONHOSP

26


Lecture 10 15

A Sample of Burn I9 Codes
94510 1ST DEG BURN LEG NOS
94511 1ST DEG BURN TOE
94512 1ST DEG BURN FOOT
94513 1ST DEG BURN ANKLE
94514 1ST DEG BURN LOWER LEG
94515 1ST DEG BURN KNEE
94516 1ST DEG BURN THIGH
94519 1ST DEG BURN LEG-MULT
94520 2ND DEG BURN LEG NOS
94521 2ND DEG BURN TOE
94522 2ND DEG BURN FOOT
94523 2ND DEG BURN ANKLE

27

Sample of Poisoning I9 Codes
96502 POISONING-METHADONE
96509 POISONING-OPIATES NEC
9651 POISONING-SALICYLATES
9654 POIS-AROM ANALGESICS NEC
9655 POISONING-PYRAZOLE DERIV
96561 POIS-PROPIONIC ACID DERV
96569 POISON-ANTIRHEUMATIC NEC
9657 POIS-NO-NARC ANALGES NEC
9658 POIS-ANALGES/ANTIPYR NEC
9659 POIS-ANALGES/ANTIPYR NOS
9660 POISON-OXAZOLIDINE DERIV

28


Lecture 10 16

Example of I9 Cardiac Surgical Procedures
3610 AORTOCORONARY BYPASS NOS
3611 AORTOCOR BYPAS-1 COR ART
3614 AORTCOR BYPAS-4+ COR ART
3615 1 INT MAM-COR ART BYPASS
3616 2 INT MAM-COR ART BYPASS
3617 ABD-CORON ARTERY BYPASS
3619 HRT REVAS BYPS ANAS NEC
362 ARTERIAL IMPLANT REVASC
3631 OPEN CHEST TRANS REVASC

29

Example I9 Neurosurgery Procedures
0102 VENTRICL SHUNT TUBE PUNC
0109 CRANIAL PUNCTURE NEC
0111 CLOS CEREB MENINGES BX
0112 OPEN CEREB MENINGES BX
0113 CLOSED BRAIN BIOPSY
0114 OPEN BRAIN BIOPSY
0115 SKULL BIOPSY
0118 OTHER BRAIN DX PROCEDURE
0119 OTHER SKULL DX PROCEDURE
0121 CRANIAL SINUS I & D
0122 REMOV INTRACRAN STIMULAT
0123 REOPEN CRANIOTOMY SITE

30


Lecture 10 17

Example I9 Orthopedic Procedures
7971 CL REDUC DISLOC-SHOULDER
7972 CL REDUC DISLOC-ELBOW
7973 CL REDUC DISLOC-WRIST
7974 CL REDUC DISLOC-HAND/FNG
7975 CL REDUC DISLOC-HIP
7976 CL REDUC DISLOC-KNEE
7977 CL REDUC DISLOC-ANKLE
7978 CL REDUC DISLOC-FOOT/TOE
7979 CL REDUC DISLOCATION NEC
7980 OPEN REDUC-DISLOCAT NOS
7981 OPN REDUC DISLOC-SHOULDR
7982 OPEN REDUC-ELBOW DISLOC

31

Example of I9 Obstetrical Procedures
734 MEDICAL INDUCTION LABOR
7351 MANUAL ROTAT FETAL HEAD
7359 MANUAL ASSIST DELIV NEC
736 EPISIOTOMY
738 FETAL OPS-FACILITATE DEL
7391 EXT VERSION-ASSIST DELIV
7392 REPLACE PROLAPSED CORD
7393 INCIS CX TO ASSIST DELIV
7394 PUBIOTOMY TO ASSIST DEL
7399 OPS ASSISTING DELIV NEC
740 CLASSICAL C-SECTION
741 LOW CERVICAL C-SECTION

32


Lecture 10 18

Section 9.2
Diagnostic-Related Groupings
(DRGs) System

The Diagnosis-related Grouping System
(DRGs)
Introduction
Design
History
Grouping Systems
Major Diagnosis Categories
Example DRGs
Diagnosis-related grouping construct

34


Lecture 10 19

Introduction
Medicare and Medicaid were adopted in 1965. Since
their adoption and for the past 45 years the expenses
for these federal funded programs have been
uncontrollable.
Many methods were attempted to reduce their annual
growth. The most radical occurred in 1980 with the
passage of public law PL-98-21 known as the
Prospective Payment System (PPS).
It mandated that hospitals rates were to be
announces the prior year before they went into effect
and rather than pay by a patients length of stay,
payment would be by the diagnoses treated.

35

What Presidential Administration?

DRG Design
A system developed at Yale known as the diagnosis-related
grouping system (DRG) was used as it currently is today, 29
years later.
The patient variables to be used in the construction of the
Diagnosis-related grouping system would consist of the
information routinely collected by hospital in its current data
collection and abstraction systems.
These included diagnosis and procedure codes, death, age, and
the existence of complications and comorbidities (CC). The
system had as its goal the creation of a manageable number of
DRGs to which payments would be assigned. Using the ICD-9-
CM coding system was ruled out due to it having thousands of
diagnoses and procedures.

36


Lecture 10 20

DRG History
1978 - HCFA funded an experiment with eighteen
New Jersey hospitals having 383 DRGs as a
prospective payment system. The ICD-8 coding
system was used to construct the DRGs.
1979 - The ICD-9-CM based DRGs were funded for
development at Yale School of Organization and
Management.
1980 - Publication of the methodology used to
construct the DRGs at Yale: Fetter R, Shin Y,
Freeman RF, Averill R, Thomson JD.(1980) Case mix
definitions by diagnosis-related groupings Medical
Care, 18 (2, Supplement pp1-53).

37 continued...

DRG History
1982 - All New Jersey hospitals used the DRGs for all
discharges including Medicare, Medicaid and all
private payors using a DRG system with 430
categories.
1983 – In 1980 public law PL-98-21 was passed
known as the Prospective Payment System (PPS).
2010 – The DRGs are into their 28th version and are
used for all Medicare discharges and applied as a
classification system for all discharge abstracts..

38 continued...


Lecture 10 21

DRG History
DRGs have been exported to France and a number of
the European 8 nations. The DRG system is designed
by a division of 3M which has been involved in its
design since its inception.
New York State uses a Non-Medicare Grouper for its
younger patients. It has more categories such as:
– The DRG 500 Series (Major Complications)
– The DRG 600 Series (Neonates)
– The DRG 700 Series (HIV)
– The DRG 800 Series (TB)

39

Grouping Systems
A grouper is a statistical program that takes the billing
claims submitted to Medicare and places them into
similar clinical and resource intense groupings.
Each group is assigned a relative weight based on the
mean charges submitted yearly. The results are
reweighing the diagnosis-related groupings (DRGs)
and the basis for rates of reimbursement for following
year. In addition new
DRGs are created based upon the use of new
technologies that are considered standards of
practice.
.

40 continued...


Lecture 10 22

Grouping Systems
Therefore in September of each year CMS will
produce a list of new adopted Medicare DRGs with
estimated payments for the upcoming fiscal year
The DRGs are divided into surgical or medical
treatments
The principal diagnosis is “the condition established
after study to be chiefly responsible for occasioning
the admission of the patient to the hospital for care.”
The principal procedure “performed for definitive
treatment rather than diagnostic or exploratory
purposes, or that was necessary to treat a
complication. The principal procedure is usually
related to the principal diagnosis.”

41 continued...

Grouping Systems
Complication or comorbidity (CC) are defined as:
– A complication is a condition that arises during the
hospital stay that prolongs the length of stay one-
day in approximately 75 percent of the cases.
– A comorbidity is a pre-existing conditions that
because of its presence with a specific diagnosis
causes an increase length of stay by at least one-
day in approximately

42


Lecture 10 23

Definitions

Medicare DRGs

Non-Medicare DRGs

43

Major Diagnostic Categories (MDC)
Diagnosis-related groupings have also been divided into categories
that follow the body systems and function as a means to group
DRGs. They are as follows:
MDC 1 Diseases and Disorders of the Nervous System
MDC 2 Diseases and Disorders of the Eye
MDC 3 Diseases and Disorders of the Ear, Nose &Throat
MDC 4 Diseases and Disorders of the Respiratory System
MDC 5 Diseases and Disorders of the Circulatory System
MDC 6 Diseases and Disorders of the Digestive System

44 continued...


Lecture 10 24

Major Diagnostic Categories (MDC)
MDC 7 Diseases and Disorders of the Hepatobiliary
System and Pancreas
MDC 8 Diseases and Disorders of Musculoskeletal
System and Connective Tissue
MDC 9 Diseases and Disorders of the Skin
Subcutaneous Tissue and Breast
MDC 10 Endocrine, Nutritional and Metabolic
Disease Disorders
MDC 11 Diseases and Disorders of the Kidney and
Urinary Tract

45 continued...

DRG Major Diagnostic Categories (MDC)
MDC 12 Diseases and Disorders of the Male
Reproductive System
MDC 13 Diseases and Disorders of the Female
Reproductive System
MDC 14 Pregnancy, Childbirth and the Puerperium
MDC 15 Newborn and Other Neonates with
Conditions Originating in the Perinatal Period
MDC 16 Diseases and Disorders of the Blood and
Blood Forming Organs and Immunological Disorders
MDC 17 Myeloproliferative Diseases and Poorly
Differentiated Neoplasms

46 continued...


Lecture 10 25

DRG Major Diagnostic Categories (MDC)
MDC 18 Infectious and Parasitic Diseases
MDC 19 Mental Disease and Disorders and Disorders
MDC 20 Alcohol/Drug Use and Alcohol/Drug Induces
Organic Mental Disorders
MDC 21 Injury Poisonings and Toxic Effects of Drugs
MDC 22 Burns
MDC 23 Factors Influencing Health Status and Other
Contacts with Health Services
MDC 24 Multiple Significant Trauma
MDC 25 Human Immunodeficiency Virus Infectious

47 continued...

Example Neurosurgery DRGs (MDC1)
DRG Description SIW
1 CRANIOTOMY AGE >17 W CC 4.9024
2 CRANIOTOMY AGE >17 W/O CC 3.1039
6 CARPAL TUNNEL RELEASE 0.6630
7 PERIPH & CRANIAL NERVE 2.8127
9 SPINAL DISORDERS & INJURIES 1.5820
10 NERVOUS SYSTEM NEOPLASMS W CC 2.2098
11 NERVOUS SYSTEM NEOPLASMS W/O CC 1.2891
12 DEGENERATIVE NERVOUS SYSTEM DIS 1.5144
13 MULTIPLE SCLEROSIS 1.1198

48


Lecture 10 26

Example Cardiac Surgery DRGs (MDC5)
DRG Description SIW
103 HEART TRANSPLANT 34.0759
104 CARDIAC VALVE PROC W CATH 8.9205
105 CARDIAC VALVE PROC W/O CATH 5.9911
106 BYPASS W PTCA 7.1890
107 BYPASS W CATH W/O PTCA 6.3165
108 OTHER CARDIO PROC 4.5258
109 BYPASS W/O PTCA OR CATH 4.6174
110 MAJOR CARDIOVASCULAR W CC 4.2513
111 MAJOR CARDIOVASCULAR W/O CC 2.8254

49

DRGs of Pregnancy, Childbirth (MDC14)
DRG Description SIW
364 D&C, CONIZATION NOT MALIGNANCY 0.6178
365 OTHER FEMALE REPRO. PROCED 1.4250
366 MALIGNANCY, FEMALE SYSTEM, W CC 1.9498
367 MALIGNANCY, FEMALE SYSTEM, W/O CC 0.9887
368 INFECTIONS, FEMALE SYSTEM 0.7375
370 CESAREAN SECTION W CC 1.0677
371 CESAREAN SECTION W/O CC 0.8620
372 VAGINAL DELIVERY W COMP DX 0.7011
373 VAGINAL DELIVERY W/O COMP DX 0.5691

50


Lecture 10 27

Case Mix Index
The case-mix index (CMI) is the sum of the total
number (N) of unique DRGs multiplied by their
DRG weights (SIWs) and then divided by the total
(ΣN)number of cases.

Σ DRG1 X SIW 1 + DRG2 X SIW2 + DRG3 ...DRGi X SIWi
Σ N1+ N2 +N3… +Ni

51

Example Case Mix Index Calculation
for Hospital A
DRG Discription Discharges (N) SIW N * Discharges
1 CRANIOTOMY AGE >17 W CC 100 4.9024 490.24
2 CRANIOTOMY AGE >17 W/O CC 150 3.1039 465.585
6 CARPAL TUNNEL RELEASE 60 0.663 39.78
9 SPINAL DISORDERS & INJURIES 200 1.582 316.4
10 NERVOUS SYSTEM NEOPLASMS W CC 150 2.2098 331.47
11 NERVOUS SYSTEM NEOPLASMS W/O CC 220 1.2891 283.602
103 HEART TRANSPLANT 32 34.0759 1090.4288
104 CARDIAC VALVE PROCEDURES W CATH 220 8.9205 1962.51
105 CARDIAC VALVE PROCEDURES W/O CATH 235 5.9911 1407.9085
106 CORONARY BYPASS W PTCA 125 7.189 898.625
107 CORONARY BYPASS W CARDIAC CATH W/O PTCA 135 6.3165 852.7275
209 MAJOR JOINT&LIMB REATTACH PROC 130 3.5778 465.114
210 HIP & FEMUR PROC EX MAJOR JOINT AGE >17 W CC 155 3.4516 534.998
211 HIP & FEMUR PROC EX MAJOR JOINT AGE >17 W/O CC 230 2.2291 512.693
212 HIP & FEMUR PROCEDURES EX MAJOR JOINT AGE <18 110 2.0625 226.875
213 AMPUTAT FOR MUSCULOSKELET SYSTEM 98 2.9877 292.7946
216 BIOPSIES OF MUSCULOSKELETAL SYSTEM 75 2.6518 198.885
218 LOW EXTREM & HUMER PROC W CC 200 2.4414 488.28
370 CESAREAN SECTION W CC 250 1.068 267
371 CESAREAN SECTION W/O CC 330 0.862 284.46
372 VAGINAL DELIVERY W COMPLICATING DIAGNOSES 623 0.701 436.723
373 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES 730 0.057 41.537
999 OTHER DRGs 15000 1.000 15000
TOTALS 19558 1.375 26888.6364

52


Lecture 10 28

Calculation of Hospital A - DRG
Revenues
CMI=1.375
Discharges=19,558
Reimbursement= $10,000 per CMI point
Patient Revenues
1.375* 19,558* $10,000=$268,992,500

53

for Hospital B
103 HEART TRANSPLANT 0 34.0759 0
370 CESAREAN SECTION W CC 1000 1.068 1068
371 CESAREAN SECTION W/O CC 500 0.862 431
999 OTHER DRGs 20000 0.900 18000
TOTALS 30771 1.068 32849.462

54


Lecture 10 29

Calculation of Hospital B - DRG Revenues
CMI=1.068
Discharges=30,771
Patient Revenues
1.068* 30,771* $10,000=$328,634,280

55

for Hospital C
103 HEART TRANSPLANT 100 34.0759 3407.59
370 CESAREAN SECTION W CC 629 1.068 671.772
371 CESAREAN SECTION W/O CC 555 0.862 478.41
999 OTHER DRGs 25000 1.500 37500
TOTALS 36570 1.664 60856.8349

56


Lecture 10 30

Calculation of Hospital C - DRG Revenues

CMI=1.664
Discharges=36,570
Patient Revenues
1.665* 36,570* $10,000=$608,892,250

57

Example DRG Construct (2)
MDC 11 D&D of the Kidney and Urinary Tract

Yes
310
Transurethral
CC No
311
Yes Yes
312
OR
CC No
Yes 313
Urethra GT17 No 314

No Other Kidney and Urinary Tract OR Proc.
315
58


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