Financial impact in APR-DRG

rania.fahmy@jefferson.edu

Hello, how to capture financial impact due to CDI queries in APR-DRG? For example how to calculate the difference between SOI 1 that changes to SOI 2 due to a query? Thanks!!

evanspx@sutterhealth.org

There is no easy answer; You would need to take a look at the contract for the payers that reimburse your site based on the APR-DRG methodology.  Typically, this involves the consideration of levels of relative weight assigned to the SOI/ROM and a formula involving a base rate.  I’d start with a conversation with the HIM Team and Finance.  Unlike the MS-DRG system, which is a system used by the Federal Gov’t,  the APR-DRG reimbursement may be used in different way in different States and by different 3rd parties.


Paul Evans, RHIA, CCDS

spitlerj@childrensdayton.org

I think it would be pretty time consuming to track/calculate your individual queries and their impact. There are different systems out there, we utilize EPIC's CDI system. It will capture a baseline review and show the impact from your final review, but that doesn't always mean there was a query involved. I think the easiest metric to track is your CMI trend. Make sure you know your baseline so you have a way to measure. I then take my baseline census/CMI and compare it to my current month's census/CMI and multiple by your "base rate", that will give you a rough estimate of your CDI programs' impact.

Hope this helps,

Jorde

evanspx@sutterhealth.org

CMI is driven by MS-DRGs, but not APR-DRG assignment..much different model.

There are payers, such as some States, that pay on the relative weight assigned in the APR-DRG system, which is not the same methodology used by CMS for payment (MS DRG).  Measuring CMI based on MS-DRG system will not reflect APR performance.  Some institutions will actually track both as separate metrics.

P. Evans, RHIA, CCDS