WHAT IS A DIAGNOSIS RELATED GROUP (DRG)?
A grouping of disease and disorders into medically meaningful sets as developed by the
Centers for Medicare & Medicaid Services (CMS).
This reimbursement system consists of established payment levels for groupings of
patients according to medically meaningful characteristics. There are six major criteria,
which are utilized in assigning a particular admission to a specific DRG. These consist
- Patient's principal diagnosis
- Procedures performed on the patient
- Patient's age
- Patient's gender
- Patient's discharge status
- Multiple diagnoses, complications or comorbid conditions.
WHAT IS A MAXIMUM ALLOWABLE PAYMENT (MAP)?
The allowable amount payable for services provided to BCBSKS members. For hospital
inpatient claims, the allowable amount is typically based on a DRG assignment.
According to the 8/22/07 Final Rule (page 47142), CMS chose MS-DRGs over the other
DRG systems because:
- MS-DRGs remains an improvement over the current CMS DRGs;
- MS-DRGs are more up-to-date (in relation to the review of MCCs &
- MS-DRGs are understandable;
- MS-DRGs are available in the public domain;
- MS-DRGs will have fewer transition issues than other systems; and
- MS-DRGs allow for updates and maintenance to continue using the same
process as under the current CMS DRGs.
Blue Cross and Blue Shield of Kansas (BCBSKS) has always utilized the standard
Medicare grouper for establishing the maximum allowable payment (MAP) for inpatient
claims. So, when Medicare decided to move towards the MS-DRGs, BCBSKS followed
and established their MAPs based on the MS-DRG (Version 25.0) grouper.
By choosing the MS-DRG grouper, BCBSKS is able to incorporate ICD-9-CM diagnosis
and procedure codes revisions into their payment structure.
WHAT IS A DRG GROUPER?
A DRG grouper is a computer program or module which takes the five clinical and
demographic data as input and gives a corresponding diagnosis related group (DRG) as
The DRG grouper that was used in 2007 for the CMS DRGs was version 24.0. This
grouper categorizes ICD-9-CM diagnosis and procedure codes to CMS-DRGs.
The DRG grouper that is being used in 2008 for the MS-DRGs is version 25.0. This
grouper categorizes ICD-9-CM diagnosis and procedure codes to MS-DRGs. Beginning
10/1/08, BCBSKS will be using version 26.0.
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