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Back  RFI # 2166: Reporting APR-DRG on 5010 835

Formal vs. Informal Help Informal Formal

Submitter

David Haugen

Description

The All Patients Refined Diagnosis Related Groups (APR-DRG) payment methodology has been licensed by over 20 state and federal agencies and by 1,600 hospitals. The MN Medicaid agency (Dept. of Human Services – DHS) is also transitioning to APR-DRGs, which are far more detailed than previous versions of DRGs and aid in payment and quality improvement.

Hospitals can’t fully reconcile accounts without the APR-DRG, but it is not clear how to report APR-DRGs via the v5010 835, and the non-835, ad hoc reporting methods now used are inefficient and expensive. Adopting a revised 835 to meet the need will take several years. Reporting APR-DRGs via the current automated v5010 835 will be far less costly than the ad hoc methods now used, and will improve the availability and use of APR-DRGs for quality and performance improvement.

DHS’s question is: What loops and segments should be used to report five-digit APR-DRGs on the v5010 835? (How should five-digit APR-DRGs be reported on the v5010 835 at this time?)

Submitter Assigned Keywords

APR-DRG v5010 835

Response

There is no direct support for APR-DRG in the 005010X221A1 guide. The Loop 2100 CLP11 can't be used for the APR-DRG since it is both too small (4 character maximum) and tied to a specific code source, code source 229.

Recommendation

Since there is one part of the 835 that is within the payer's total control, that is the only possible location for conveying APR-DRG information using the entire 5 characters - use the 2100 Loop Other Claim Related Identification REF segment with REF01 equal to CE (meaning "Class of Contract Code"). Guide section 1.10.2.15 states "The specific need for identification is determined by the business alignment of the health plan and how that determines payment to providers rather than any objective concept of network or product line."

The REF02 element supports 50 characters, allowing the payer to specify that they will identify their contract and the related applicable APR-DRG using a format like "Contract - APR-DRG". For example, if the line of business is "Premier PPO" and the APR-DRG is "12345" then the value in REF02 would be reported as "Premier PPO - 12345". As long as that doesn't exceed the 50 character maximum size, there should be no problem. Of course, the format and usage should be conveyed to providers via any trading partner agreement or companion guide.
Submission 7/28/2016
Status Date 9/30/2016
Status F - Final
Primary References
Document 005010X221
Sectionunknown