Integrated MS-DRG Grouper & Calculator Printable How To Guide

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1 Integrated MS-DRG Grouper & Calculator Printable How To Guide MediRegs provides an integrated MS-DRG Grouper & Calculator that demonstrates MS-DRG grouping and payment under the Inpatient Prospective Payment System. The MS-DRG Analyzer upgrade extends the Grouper & Calculator to allow for batch processing of coding data and deeper payment analysis. These tools are excellent companions to the codebooks, the ICD-10 Explorer, and the NHA Payment System Data Files. Background Information The MS-DRG Grouper allows you to see how ICD diagnosis and procedure codes group into Medicare Severity Diagnostic Related Groups (MS-DRG) under the Medicare Inpatient Prospective Payment System (IPPS). The grouper logic is provided by the Center for Medicare and Medicaid Services; the interface to that logic allows you to enter a claim manually or with a batch upload and get results on screen or in downloadable format. The MS-DRG Calculator & Analyzer performs a provider-specific calculation of the MS-DRG assigned. The calculator logic is based on the IPPS Final Rule Table 5 for MS-DRG weights, and the CMS IPPS Final Rules and PC-Pricer for provider variables. Using the Integrated MS-DRG Grouper & Calculator When you first enter the calculator, you will have two options: - If you already know the MS-DRG codes, click on the Calculate button at the top of the screen for a simplified data entry panel. - If you want to group a single claim for which you have ICD diagnosis and procedure code, click on the Group/Calculate button for a more detailed data entry panel. - Note: Users who have upgraded to the MS-DRG Analyzer also have the ability to group up to 200 claims at once using a simple excel upload feature, and perform more complex payment analyses including outlier adjustments, blended/base rate, per diem calculations and more.

2 2 To calculate payment by entering MS-DRG codes If you already know the MS-DRG code(s), click on the Calculate button at the top of the screen. The Calculator data entry panel allows you to enter Provider ID, Discharge Date, MS-DRG Code(s) and Length of Stay. Fields labeled in red are required. You can enter a single or multiple MS-DRG codes (separated by commas or spaces), and calculate the national unadjusted or provider-specific adjusted payment. Note: Grouping logic will historically group to 1999, but payment information is only shown for the last five years. Step-by-Step Instructions 1. Enter a provider id, or type the name of the hospital in the Enter Provider ID box. As you type, notice autosuggest options that you can click on. TIP: If you want to calculate the national unadjusted payment rate, click the National Unadjusted link. TIP: Use the Advance Provider Search to identify a provider ID by Name, ID, Zip, State, City, County or Address. After entering your search term, select the appropriate provider. 2. Enter the MS-DRG(s) in the Enter MS-DRG Code box. You can also click on the Search link to see a search by MDC or MS-DRG that auto-suggests based on your search. You can search a single code, a list of codes (separated by commas or spaces), or use the APPEND option in the lookup to create a list of codes as you search. 3. Enter the discharge date in the Discharge Date box, or leave this blank to calculate for the most recent date available. 4. Enter the Length of Stay, in the Length of Stay box which is a number of days, or leave this blank to default to Click Calculate. Results appear on screen. You can export the on-screen report in PDF or XLS format by using the Export button at the top of the screen. 6. If you wish, you can Bookmark the search parameters to re-execute in the future. 7. To start over, click the Reset button to clear all entered values and results.

3 3 To calculate payment by entering ICD-9 or ICD-10 codes If you want to group and calculate payment for a single claim for which you have ICD diagnosis and procedure codes, click on the Group/Calculate button. The Grouper data entry panel allows you to enter Provider ID, Patient Information, Patient Stay Information, and ICD Codes. Fields labeled in red are required. Choose either the ICD-9 or ICD-10 code set in the dropdown menu. Note: You have three options for payment: HIDE payment information by checking the box, click the National Unadjusted link to calculate the national unadjusted rate, or enter a hospital name/id to calculate provider-specific payment rate for any discharge date within the last five years. Step-by-Step Instructions 1. Enter a provider id, or type the name of the hospital in the Enter Provider ID box. As you type, notice autosuggest options that you can click on. TIP: If you want to calculate the national unadjusted payment rate, click the National Unadjusted link TIP: Use the Advance Provider Search to identify a provider ID by Name, ID, Zip, State, City, County or Address. After entering your search term, select the appropriate provider. 2. Optional: if you wish to suppress the calculation and just show grouping and edit logic, check the Hide Provider and Payment Details box. 3. Enter patient information, including Birthdate, Age (on discharge date) and Sex. Age is required. 4. Enter patient stay information, including selecting the payor and discharge status, and entering the admit date, discharge date and length of stay (LOS). The discharge date is required. Primary payor and discharge status are set to default values which you can change using the drop down menu. 5. Toggle to enter either ICD-9 or ICD-10 codes. Admission Diagnosis and Principal Diagnosis are required. All other codes are optional. Select the Present On Admission indicator next to each code from the drop down menu. Use the scroll bar to add more codes. Enter procedure codes if applicable. 6. When you are done with data entry, scroll to the bottom and click Group & Calculate. Results appear on screen. You can export the on-screen report in PDF or XLS format by using the Export button at the top of the screen.

4 4 7. If you wish, you can Bookmark the search parameters to re-execute in the future. 8. To start over, click the Clear Form button to clear all entered values and results. Using the MS-DRG Analyzer Upgrade To group and calculate payment based on a batch of claims Note: this feature is available for subscribers who have upgraded to the MS-DRG Analyzer If you want to group and calculate payment for a set of claims for which you have ICD diagnosis and procedure codes, click on the Batch Upload button. The Grouper data entry panel allows you to enter Provider ID and then upload a properly formatted claims data file for batch processing. Instructions, sample claims, and a template file are available to download on the right. Note: You have three options for payment: HIDE payment information by checking the box, click the National Unadjusted link to calculate the national unadjusted rate, or enter a hospital name/id to calculate provider-specific payment. ***Note 200 row/ 250kb batch limit Step-by-Step Instructions 1. Before you begin, download the sample claim file (with or without detailed information). Save the file in CSV or XLS format (XLSX is not supported). The file has detailed instructions and examples about how the data should be formatted. 2. When your data file is ready, enter a provider id, or type the name of the hospital in the Enter Provider ID box. As you type, notice auto-suggest options that you can click on. TIP: If you want to calculate the national unadjusted payment rate, click the National Unadjusted link. TIP: Use the Advance Provider Search to identify a provider ID by Name, ID, Zip, State, City, County or Address. After entering your search term, select the appropriate provider. 3. Optional: If you wish to suppress the calculation and just show grouping and edit logic, check the Hide Provider and Payment Details box. 4. Click Group & Calculate. Results appear on screen. If you wish, export the on-screen report in PDF or XLS format by using the Export button at the top of the screen. If you have used the batch uploader, there are 2 XLS options: the first report shows the MS-DRG payment results, the second returns the same file you entered with the MS-DRG and error notes columns appended all the way to the right of your data.

5 5 Files available for download for use in the Batch Uploader claims-sample.xls This is an Excel file with multiple rows to show example grouper logic and common messages that can happen when there are data entry errors or grouper edits. claims-instructions.xls This is an Excel file with detailed instructions and lookup values for codes.

6 6 To analyze MS-DRG Payment and perform special calculations Note: this feature is available for subscribers who have upgraded to the MS-DRG Analyzer. If you want to perform outlier, state, regional or other comparisons, click on the Analyze button. The Analyzer data entry panel allows you to enter Provider, State or Region; an MS-DRG, discharge date, Length of Stay, Charges for Outlier calculation, and a multiplier. Please see special instructions below for Provider/State/Region Calculations. Special Payment Calculations available in the Analyzer Pricer Report: Click on the pricer report to get a version of the calculation aligned to the CMS PC Pricer report. Outlier Payment Calculation: When you enter charges in the data entry panel, the Analyzer will check to see if the outlier threshold has been met and display the outlier payment if applicable. Note: You must enter provider/state/region, MS-DRG, LOS and RUN prior to entering the total charges Adjusted Payment Calculation: When you enter a multiplier (any number greater than zero) in the data entry panel, the Analyzer will calculate the base Medicare Expected Payment rate, and the adjusted rate, based on the multiplier. Multiplier defaults to one if not changed. State and Regional Average Calculation: See more details below. Side-by-Side Payment Comparison & Benchmarking: After you have run a calculation for a given payment scenario, click the Copy Last Column button, make changes to the scenario in the next column, and click RUN at the bottom of the new column. Alternatively, click the New/Blank Column button to add a blank column. The first column will become the BASE for the analysis; change the base by checking the box on a different column and clicking RUN again on each column. Per Diem Calculation based on Length of Stay: Enter any Length of Stay you wish. The results will show the per diem calculation based on the published GMLOS and the one you have entered. Length of stay defaults to 1 if not changed. Health Reform Impact Analysis: This is calculated automatically for each column. The results will show the Medicare Expected Payment using the standard calculation, and then show the theoretical payment that would result without performance adjustments.

7 7 Advanced Provider/State/Region Search The Analyzer has advanced capabilities to browse lists of facilities by state/region, or to calculate state/regional averages. Common scenarios are detailed below: To Calculate for a known provider To Calculate National Unadjusted To Calculate State Average To Search for a provider To Calculate County Average Type the provider name/id in the Provider input box, or click the search button and search by address. Enter the provider number (that is six zeroes) in the Provider input box; or click the National Unadjusted link near the provider box Enter the 2 character initials (KY, MA) in the Provider input box; results will show how many providers are in the state, and that can be expanded to choose any provider from the list. Click on the Search button next to the Provider Input box. Select Search by Provider. Enter name or address information, click Search and select the provider from the list. Click on the Search button next to the Provider Input Box. Select Search by Region and Analyze by Region. Enter the 2 character initials for the state in the State box. Choose the county from the drop down menu and click SUBMIT. To browse/search for a provider by region Click on the Search button next to the Provider Input Box. Select Search by Region and Search for Provider. Enter the 2 character initials for the state, and then select a county in the Region drop down and then a provider in the list.

8 8 Modifying Provider Variables in the Analyzer After you have run a calculation, you can modify provider variables to run what if and other analyses. As you change variables, the calculated payment amounts automatically adjust. You can change any variable that appears with blue dashed underline. After you ve changed variables, they are highlighted and you can revert back to the original, published value by clicking on the X. The modified results are indicated with red highlighting and the M symbol Creating a Bookmark If you wish to save a session, scroll to the bottom of the column and click ADD BOOKMARK and provide a name. If you ve modified variables, that will be indicated. Once you ve created a bookmark, you will have the option at the top of the screen to Use Bookmark anytime.

9 9 On-Screen Results Your results screen will vary depending on whether you have used MS-DRGs or ICD codes, or if you have entered a single claim or multiple, or selected to hide payment information. The results screen keeps your search parameters at the top; scroll down for results. MS-DRG Calculator Results This summarizes payment information for one to many MS-DRGs. No ICD-CM coding information is shown. ICD Grouper & Calculator Results This summarizes coding and payment information for one MS-DRG if you used the Grouper/Calculator data entry panel, or up to 200 MS-DRGs if you used the Uploader. Provider Information This summarizes how the hospital is generally paid, along with the dates of the stay. A list of the changes to the provider s variables is available by clicking on Link to History of Provider Variables. MS-DRG Payment Information Here you see the provider-specific payment rate for each MS-DRG, with the calculation broken down into detail.

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11 11 ICD Coding and Grouping Information If you have provided ICD-CM codes, coding information and Medicare Code Edit messages will appear. A history of payment for the MS-DRG is available by clicking the SHOW HISTORY button. Special Payment Analysis Information The MS-DRG Analyzer results are presented in simple table format. At the top, you will see basic Medicare Expected Payment Information, broken out by portions. Scroll down for additional details.

12 12 Detailed explanation of Analyzer Results Screen Provider Details The orange icon next to the hospital name indicates the adjustment taken based on Quality Reporting and Meaningful Use. The blue icon next to the hospital name shows additional provider details. CMS Top 100 Utilization Information If you are running calculation for an MS-DRG that is in the CMS published top 100 MS-DRGs by utilization, a blue icon appears in the MS-DRG Results. Click on the CMS Top 100 icon to see additional details specific to this provider and MS-DRG.

13 13 Payment Comparison View If you have chosen to make new columns, results appear with all columns compared to a BASE column as designated with the check box. You can change your base by checking the desired column.

14 14 Outlier Calculations In the Special Analysis section, the Analyzer automatically provides a calculation to determine if the payment scenario is eligible for an outlier payment based on the entered charges. The outlier payment is broken down by operating and capital portions and the impact to the total Medicare payment is shown. Asking What If Analysis questions In the provider results, there is a list of variables which appear with dashed blue lines. Those can be edited and the calculation can be re-run to see how reimbursement is impacted by changes in provider variables. Manually changed variables will appear in Red And Modified results will be highlighted with the M symbol appearing.

15 15 Health Reform Impact Analysis In the Special Analysis section, the Analyzer automatically provides a calculation that demonstrates how the provider s Base reimbursement is impacted by the performance variables. This is shown as below. You can also edit variables on your own as described above to do your own custom analysis. Per Diem Analysis In the Special Analysis section, the Analyzer automatically provides a calculation that demonstrates the per diem based on the Geometric Mean Length of Stay (GMLOS) as published by CMS for the MS-DRG and the actual length of stay (LOS) entered. Multiplier Payment Adjustment In the Special Analysis section, the Analyzer reflects multiplier impact to the Medicare Expected Payment by multiplying the calculated rate by for the entered multiple for calculating contract rates.

16 16 Additional On Screen Information Source Information Here you see details about the variables used to create the calculated payment shown above, as well as details about the source of the data. Note: The CMS PC Pricer is the source for these variables, and it is updated with corrections regularly. Sometimes these corrections are retroactive. Documentation At the bottom of the screen is the documentations section with tabs to see the calculation logic, the assumptions made in those calculations, and additional information. Special Features Saving your results Bookmarking You can save your MS-DRG Calculator search criteria to reuse later. Click on the BOOKMARK button next to the CALCULATE button, Name your bookmark and save. You can retrieve a saved bookmark or delete it by clicking on the Your Bookmarks link on the top menu bar.

17 17 Exporting your results If you would like to export or print your report, click on the EXPORT link in the top menu bar, and choose either PDF or EXCEL format. The basic MS-DRG Excel report provides a summary of MS-DRG and payment information only. If you have used the upload capability, a second Excel option is available, this will include your original data input, and the MS-DRG output and edit notes will be all the way to the right. When using the Analyzer, select CSV, PDF or Pricer Report at the top of the column to export the analysis. The PDF and CSV versions simulate what you see on screen, and the Pricer version simulates what you see when you use the CMS PC Pricer.

18 18 Examples for you to try Here are some example queries you can try in the MS-DRG Calculator to demonstrate functionality and interesting Inpatient PPS logic. Search term Very Simple Report Code subject to Acute Care Transfer policy Provider payment differences Payment differences over time Code Set Demonstrates: Provider: MS-DRG: 392 Date: leave blank DRG: 003 Notice the Acute Care Transfer Flag. After generating any report, try entering a different provider to see how the payment can vary from one provider to the next. After generating any report, try entering a different year to see how payment rates change over time. NOTE: The relative weight for DRGs change yearly, but the provider-specific variables can change throughout the year. For a reimbursement rates for any given department/specialty, enter the set of MS-DRGs related to that specialty (separate codes with a space), or use the SEARCH feature to search by Major Diagnostic Category Additional Information While the MS-DRG Calculator is an excellent tool for understanding MS-DRGs reimbursement, you may also find helpful information in the following resources: Medicare Code Editor (MCE) Manual describes the edits that inpatient claims are subject to and includes lists of codes and changes. This resource is located in both the CMS ICD-10 and Acute Inpatient PPS collections. MS-DRG Definitions Manual lists all MS-DRGs, and explains diagnosis and procedure grouping logic. Available under Codebooks & Guidance. ICD CodeBooks: Use the ICD-9-CM, ICD-10-CM and ICD-10-PCS Codebooks to navigate code descriptions, search the index, and read critical coding guidelines. Find CC/MCC and other edit lists there.

19 19 MS-DRG Payment Book shows historical information for DRGs and MS-DRGs and includes helpful tables and indexes. MS-DRG Grouper allows you to group a patient case into an MS-DRG with ICD-9 or ICD-10 codes. Search Tips Sometimes it is handy to search for an entire list of MS-DRGs by specialty. To generate a list of MS-DRGs, click on the SEARCH link. Enter key words in the MDC Lookup box to choose from the list. A list of MS-DRGs appears and you can check some or all, or append to your current list of codes. Source Information The MS-DRG Calculator assists you with determining appropriate payment under the Hospital Inpatient Prospective Payment System. This tool performs a database query of the IPPS Table 5 then calculates a provider-specific payment. The variables used in the calculation for each provider are extracted quarterly from the IPPS PC Pricer published by CMS. Updates to the payment logic are incorporated yearly; logic changes are discussed in the IPPS Proposed and Final Rules. Archives The MS-DRG Calculator allows payment calculations for the current and past 4 Fiscal Years. Additional archives (10/1/2005 to 9/30/2013) are available in a retired version of the calculator. Go to the Codebooks (archived years) library and scroll down. You will also find additional archives available for the MS-DRG ICD-9 and ICD-10 Pilot grouper here as well. Licensed Coding Guidance The American Hospital Association Coding Clinic for ICD-9-CM and ICD-10-CM and ICD-10-PCS are available in the Compliance & Regulation Suite Plus and the Audit & Revenue Resource Center. Look under the CodeBooks & Guidance heading on the left-hand navigation pane. Daily Alerts SUPPORT Daily Alert: Watch for yearly updates to IPPS in the CMS Federal Register, which will be posted to the Daily What s New Alert. The MS-DRG CodeBook also includes an Updates & Changes report and Download Center which will appear in the Daily Alert. Your Feedback is Welcome! Please let us know if you have any questions, suggestions, or feature requests. You can reach out three ways: Browse the KnowledgeBase or Submit a Ticket at Send an to Support@MediRegs.com. Call