Diagnosis Related Groups also known as DRGs was created in the early 1970s by Yale University to explain the different types of care provided to patients that were admitted to an acute healthcare facility (Evolution of DRGs (2010 update), 2010). According to Castro (2013), the plan for DRGs initially was to have a classification system that would keep track of the quality of care as well the services provided in a healthcare (p. 126). Sayles (2013) states that in the early 1980s, The Centers for Medicare and Medicaid (CMS) implemented a prospective payment system (PPS) for Medicare beneficiaries that were admitted to a healthcare facility requiring inpatient care, this PPS was known as the diagnosis related groups (DRGs) (p. 264). The DRG …show more content…
According to Castro (2013), initially there were 23 MDCs which represented the body system as well as a group for DRGs that corresponded with all of the MDCs and pre-MDC, for example disease and disorders of the digestive system (p.128). In an updated version of the DRG system the Human Immunodeficiency Virus Infections and Multiple Significant Trauma categories were added. The next part of the MDC group is divided into two groups known as medical and surgical (p. 128). The final level divides the DRGs into surgical and medical in the 25 MDC groups, for example, surgical procedures that were performed on the patients and medical diagnosis for when the patient was admitted (p.128). The title, geometric length of stay, arithmetic mean length of stay, relative weight, and ICD-10-CM code range that drive the DRG assignment are the component of each DRG version (Evolution of DRGs (2010 update), 2010). The principal diagnosis, surgical procedures, or diagnosis procedure combinations are to be included in the code range (p.128). The DRG system has been beneficial to healthcare facilities, but in 2008, the Centers for Medicare and Medicaid (CMS) introduced a new system called the Medicare Severity Diagnosis Related Groups …show more content…
In order for a healthcare facility to be reimbursed for more severe cases, a severity component needed to be added. Therefore the DRG system was changed to the MS-DRG system . According to Castro (2013), the MS-DRG system uses major complication/comorbidity (MCC) diagnosis codes and complication/comorbidity (CC) diagnosis codes to get a better number of sub classifications (p. 128). The CC list was updated, as it had lacked revision, each code was considered a CC or MCC in which the CC list became two separate lists for the MS-DRG. About 730 codes were removed from the list, but important codes were added such as acute disease, acute exacerbations of chronic conditions, and end-stage chronic disease (p.129). According to Sayles (2013), when assigning MS-DRGs, groupers are used to help coding and reimbursement staff to assist in proper payment for services provided, grupers are known as computer programs that assign patients to case-mix groups (p. 267). There is a four step process used to assign MS-DRGs for inpatients (Evolution of DRGs (2010 update), 2010). 1) Pre-MDC assignment, 2) Major Diagnostic Category Determination, 3) Medical and Surgical Determination, 4) Refinement (p.132). In order to calculate the MS-DRG payment, Medicare requires a four step process. This process includes Medicare Administrative Contractors that use grouper and pricer software to get
The IPPS or the inpatient prospective payment system refers to a system of payment which includes the diagnosis-related groups’ cases as acute care hospital inpatients. This system is based on resources which are utilized when treating Medicare recipients belonging to these groups. Each diagnosis-related group (DRG) comprise of a payment weight. The IPPS serves an integral role when it comes to deciding the overall hospital costs of all the devices used to treat the patient in within a specific inpatient stay.
Major Assumptions Once health care professionals have a firm foundation on Mishel’s uncertainty in illness theory, understanding the theory’s assumptions will assist nurses to apply evidence-based practice to real world situations. For example, in Mishel’s reconceptualized version of the theory, the major assumption is related to uncertainty and the way in which individuals function when presented with a chaotic state (Mishel, 2011). A fluctuation in control can create chaos while enhancing an individual’s willingness to change (Alligood, 2014). Uncertainty occurs when an individual cannot adequately categorize an illness-related event because of lack of sufficient cues (Alligood, 2014). This uncertainty in life can take many forms.
Baptist Memorial Hospital is in a highly competitive healthcare environment. This capitation is not only the result of efforts of the other healthcare organizations but, also driven by patient consumerism. The government sponsored hospital compare website allows potential patients the ability to compare our clinical outcome data. The targeted group is also the group with the greatest healthcare choice, our medicare population. One of the major reporting categories is Hospital acquired condition, the most significant of these is hospital aired infections. The significance of the website data is:
Generally, the development and adoption of Clinical Decision Support (CDS) systems is based on the necessity and essence of technical standards in enhancing healthcare. However, the various health IT tools must comply with some data interchange standards in order to enhance access to clinical records, lessen clinical errors and risks to patient safety, and promote innovation in “individual-based” care (Hammond, Jaffe & Kush, 2009, p.44). The need for compliance with standards is fueled by their role in enabling aggregation of informa...
If patients constantly have to wait an excessive amount of time they will either leave before they receive care or could end up becoming sicker as a result. Donabedian’s three-element model structure, process and outcome have become the gold standard for defining quality measurement (Varkey, 2010). Structure relates to the health care setting, which includes the hospital policies, procedures and design. Process evaluates if the right actions were taken for an intended outcome and how well the actions were executed to achieve the outcome. Outcome focuses on the patient, it measures the patient’s condition, behavior, and response to or satisfaction with care (Varkey, 2010). Although each of these measures focus on different areas, they indicate areas that need improvement. Also, the measurement from structure and process plays an important role in the patient’s outcome. If the hospital has the right staff, equipment and
Considering the conflicting findings amongst the different EWS, it remains unknown whether these scoring systems are effective in identifying and responding to deteriorating patient in acute hospital settings. This essay intends to establish how successful, if at all, the EWS in particular SHEWS is in identifying deteriorating patients in acute surgical hospital settings. In order to do this we will be returning to patient X, a 22-year-old Asian female with a diagnosis of acute pancreatitis. By comparing the evidence base to reality I hope to get a better understanding of how effective this tool is in identifying deteriorating patients.
The implementation of the Clinical Decision Support System (CDSS) was to allow physicians the ability diagnoses patients with the use of evidence based decisions. Physicians can explore relevant medical information through the CDSS from reliable medical experts, clinical guideline extractions and alerts of new and different phases of patient management without the interruption of the medical organization’s workflow (Chiarugi, Colantonio, Emmanouili...
`In the past, I worked in such a research setting, where if a person was found to meet criteria for opiate dependence they received treatment, however if even slightly short of DSM-IV criteria for the disorder they would have to look elsewhere. This was a continual concern for me, as the person who met criteria was not always the person with the most distress, and alternative treatments were not easy for people to find. Largely from this experience, I find the current categorical approach to classifying persons with psychopathology to be an imperfect system at best, with the primary advantage of being convenience when communicating with other professionals. I question whether this convenience comes at a severe cost to accuracy, the result of which is an artificial limit to the range of presentations that occur in psychopathology. As the example above illustrates, the particular aspect that I find most problematic is the use of cutoffs for specific symptoms, for instance the length symptoms must have been present for it to be classified as a disorder, or even the number of symptoms that need to be present. I think it is unlikely that a person who “almost” meets criteria for a disorder would be significantly different from a person with similar symptoms who just barely meets criteria. In private practice these two cases would likely be treated similarly, but in a setting where diagnosis serves as a screening tool the client who met criteria may get treatment while the other does not. In this case I feel that less specific guidelines, lacking specific numerical limits would alleviate many of the problems.
Hoffman, G., & Jones, D. (1993). Prebilling DRG training can increase hospital reimbursement. Healthcare Financial Management: Journal Of The Healthcare Financial Management Association, 47(9), 58.
Quality patient care is an ongoing endeavor that involves many different areas of healthcare. One area of healthcare that is often employed is Utilization Management. We read in John’s that UM “is composed of a set of processes used to determine the appropriateness of medical services provided during specific episodes of care” (John,2011). Things that are used to determine the appropriateness of care include the patient’s diagnosis, site of care, length of stay, and other clinical factors. This system consists of three main functions aimed at improving patient care and controlling healthcare costs. These functions include utilization review, case management, and discharge planning. One source states that it also includes the claim denials and appeals process (Interviewee C. Jarvis, e-mail communication, May 3, 2014). When used correctly, these UM processes can expedite the patient’s care and reimbursement. It also demonstrates to third party payers that the organization is taking measures to help control costs. This monitoring and management of patient healthcare needs ensur...
Case 1 -- You work in a busy multi-specialty clinic with a high patient volume. The physicians enter the type of code that will yield the greatest reimbursement. You suspect the codes are not accurate.
Hospitals recognized the need for the case management model in the mid 1980’s to manage the lengths of stay of hospitalized patients and the treatment plans (Jacob & Cherry, 2007). In 1983, the Medicare prospective payment program was implemented which allowed hospitals to be reimbursed a set payment based on the patient’s diagnosis, or Diagnosis Related Groups (DRG), regardless of what treatment was provided or how long the patient was hospitalized (Jacob & Cherry, 2007). To keep the costs below the diagnosis related payment, hospitals ...
reimbursement determinations. As a result, the camaraderie among physicians has developed into a more aggressive approach to impede competition (Shi & Singh, 2012). Little information is shared with patients in regards to procedures or disease control. The subjects are forced to rely on the internet for enlightenment on the scope of their illnesses (Shi & Singh, 2012). Furthermore, the U.S. health care system fails to provide adequate knowledge on billing strategies for operations and other medical practices. The cost in a free system is based on supply and demand and is known in advance of hospital admission (Shi & Singh, 2012). The need for new technology is another characteristic that is of interest when considering the health care system. Technology is often v...
According to Toseland and Rivas (2005), group dynamics are “the forces that result from the interactions of group members” (p. 64). These forces refer to either the negative or positive influences towards meeting members’ socioemotional needs as well as goal attainment within a group (Toseland & Rivas, 2005), like within my class work group experience. Some of dynamics that continue to emerge and develop in my group is the effective interaction patterns and strong group cohesion, which has generated positive outcomes and group achievement thus far.
This working document provides a summary of the Case Coordination Group (CCG) Review’s initial assessment of the CCG operations and a ‘first cut’ of draft proposals for change or modification to those operations.