DRG system-Method of payment of hospital health care

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• DRG system-Method of payment of hospital
  health care
• Introduction
• Advantages
• Statistics

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Introduction -performance of the implemented
reform -performance indicators


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• Advantages
• Central Data Base
• Possibility for peer hospitals comparison
• Occupancy of hospital capacities
• Increase of efficiency in usage of resources
• Planning of type and volume of services

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• Statistical analysis of DRG data
• Number of recorded cases
• CMI
• ALOS (average length of stay in hospital)
• Most common DRG groups
• Most common diagnoses
• Most common DRG groups
• Most common diagnoses
• Error DRG codes
• Occupancy of hospital capacities

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• Coding rules
• Principal diagnosis
• Secondary diagnosis
• Procedures

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Principal diagnosis Definition
Diagnosis that is confirmed to be a major cause
for hospital treatment after all analyses
performed
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• Secondary diagnosis
• Definition
• Condition or problem that either exists together
  with the principal diagnosis or it appears
  during the hospital treatment of the patient.
• additional diagnoses are to be interpreted as
  a conditions that influence the treatment of the
  patient concerning the need for
• diagnostic procedures and treatment
• enhanced care and/or monitoring

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• Procedures
• Clinical intervention that fulfills one or more
  of the following criteria.
• It is surgical by nature
• It bears a procedural risk
• It bears an anaesthesia risk
• Requires special training
• Requires special spatial facilities or equipment
  only available in the institutions for provision
  of acute health care

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• Instructions for coding
• Daily Hospital (DH)
• Daily Hospital Records (DHR)
• Dialysis
• Transfer from Department to Daily Hospital and
  vice versa

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• Daily Hospital (DH)
• Single day hospitalisation that last less than 24
  hours in order to perform invasive diagnostic and
  therapeutical procedures (gastroscopy, biopsy,
  colonoscopy, closed reposition of a fracture)

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• Daily Hospital Records (DHR)
• Single day hospitalisation that last less than 24
  hours and is only for application of specific
  (biological) therapy, chemotherapy and chronical
  dialysis treatment

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• Dialysis
• when a patient on a chronical dialysis treatment
  will be admitted to a hospital to be provided
  other hospital care services, for the same a DRG
  is prepared according to the coding rules for the
  actual admittance, but without stating the
  procedure for dialysis according to DRG.
  Chronical dialysis treatment is invoiced to the
  Fund according to the price that is established
  by the Fund.

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• If the patient is not on a chronical dialysis
  treatment, but during the time of treatment an
  acute renal insufficiency occurs, then in the DRG
  coding the acute renal insufficiency will be
  inserted as principal or secondary diagnosis
• ( according to the coding rules), as for the
  dialysis procedure too.

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• Transfer from Department to the Daily Hospital
  and vice versa
• In a case when condition of the patient treated
  in the daily hospital get worse and he is
  hospitalised, after discharge he is coded
  according to DRG for the period of
  hospitalisation but also the procedures are
  inserted that were performed in the daily
  hospital.

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• The patient treated in the stationary, and
  afterwards transferred in a daily hospital is
  coded only according to DRG for the period of
  hospitalisation.

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• Most common errors during DRG coding
• Giving of improper principal diagnosis
• Insertion of improper secondary diagnosis
• Insertion of improper and/or incorrect procedure

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Review of the DRG code ?60 in PHI
PHI Title O60A   O60B   O60C   Total
  ???? ?? ?????? ???? ?? ?????? ???? ?? ??????  
GYNAECOLOGY AND OBSTETRICS CLINIC SKOPJE 305 9,58 1.313 41,24 1.566 49,18 3.184
PHI SPECIAL HOSPITAL FOR GYNAECOLOGY AND OBSTETRICS CAIR 66 3,21 456 22,19 1.533 74,60 2.055
CLINICAL HOSPITAL TETOVO 3 0,19 17 1,09 1.541 98,72 1.561
PHI GENERAL HOSPITAL KUMANOVO 30 2,31 674 51,89 595 45,80 1.299
CLINICAL HOSPITAL BITOLA 23 2,71 330 38,82 497 58,47 850
PHI GENERAL HOSPITAL STRUMICA   0,00 29 3,21 875 96,79 904
PHI GENERAL HOSPITAL PRILEP 14 1,50 415 44,58 502 53,92 931
CLINICAL HOSPITAL STIP 3 0,48 20 3,22 598 96,30 621
PHI GENERAL HOSPITAL GOSTIVAR 1 0,14 14 1,96 700 97,90 715
PHI GENERAL HOSPITAL VELES 1 0,17 16 2,76 563 97,07 580
PHI GENERAL HOSPITAL STRUGA   0,00 23 6,28 343 93,72 366
PHI GENERAL HOSPITAL KAVADARCI 5 1,17 14 3,27 409 95,56 428
PHI GENERAL HOSPITAL OHRID 6 1,52 187 47,34 202 51,14 395
PHI GENERAL HOSPITAL KICEVO   0,00 28 9,43 269 90,57 297
PHI GENERAL HOSPITAL KOCANI 5 1,37 16 4,40 343 94,23 364
PHI GENERAL HOSPITAL GEVGELIJA 2 1,31 91 59,48 60 39,22 153
PHI GENERAL HOSPITAL DEBAR   0,00 7 3,89 173 96,11 180
In total 464   3.650   10.769   14.883
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Review of the DRG code P67 in PHI
  P67D P67D P67D P67C P67C P67C P67B P67B P67B P67A P67A P67A
HI Title Number of cases Days (AVG) Number of cases Days (AVG) Number of cases Days (AVG) Number of cases Days (AVG)
Total 12.162 62,19 3,01 6.627 33,89 4,67 665 3,40 7,14 101 0,52 14,69
GYNAECOLOGY AND OBSTETRICS CLINIC SKOPJE 2.445 61,51 2,41 1.464 36,83 3,93 55 1,38 9,36 11 0,28 17,73
PHI SPECIAL HOSPITAL FOR GYNAECOLOGY AND OBSTETRICS CAIR 1.844 70,01 2,92 640 24,30 5,15 142 5,39 5,88 8 0,30 9,13
PHI GENERAL HOSPITAL TETOVO 1.731 82,78 2,56 352 16,83 3,78 8 0,38 6,50   0,00  
PHI GENERAL HOSPITAL KUMANOVO 645 41,21 2,88 874 55,85 5,09 40 2,56 6,38 6 0,38 8,33
PHI GENERAL HOSPITAL STRUMICA 1.001 77,36 2,95 273 21,10 4,76 20 1,55 5,65   0,00  
PHI CLINICAL HOSPITAL BITOLA 944 75,76 3,97 267 21,43 5,90 28 2,25 6,93 7 0,56 17,00
PHI GENERAL HOSPITAL PRILEP 306 28,28 3,63 631 58,32 4,48 141 13,03 5,92 4 0,37 9,25
PHI GENERAL HOSPITAL GOSTIVAR 526 60,39 4,53 326 37,43 6,27 18 2,07 8,39 1 0,11 14,00
PHI GENERAL HOSPITAL STIP 469 53,91 3,56 393 45,17 4,02 7 0,80 5,29 1 0,11 7,00
PHI GENERAL HOSPITAL VELES 519 74,04 2,73 150 21,40 4,23 32 4,56 6,47   0,00  
PHI GENERAL HOSPITAL STRUGA 490 88,61 3,47 54 9,76 5,19 9 1,63 5,56   0,00  
PHI GENERAL HOSPITAL OHRID 176 35,41 4,02 308 61,97 5,28 13 2,62 7,46   0,00  
PHI GENERAL HOSPITAL KAVADARCI 126 24,66 3,24 378 73,97 4,48 7 1,37 4,43   0,00  
PHI GENERAL HOSPITAL KICEVO 362 90,95 2,73 34 8,54 3,03   0,00   2 0,50 7,00
PHI GENERAL HOSPITAL KOCANI 241 64,78 3,19 130 34,95 3,44 1 0,27 7,00   0,00  
PHI GENERAL HOSPITAL GEVGELIJA 105 47,09 4,31 116 52,02 5,47 2 0,90 5,50   0,00  
PHI GENERAL HOSPITAL DEBAR 172 78,54 2,85 42 19,18 4,17 5 2,28 3,00   0,00  
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• NEWS

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• Review of the incorrect (error) DRG codes for
  hospitals

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• Way of coding and invoicing of transfers
• In a case of transfer of the patient from clinic
  to clinic, each clinic creates its own DRG code.
• The patient is discharged with type of discharge
  transfer with an interclinical referral and a
  copy of the blue coupon

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• New field in the DRG grouper for insertion of
  the facsimile number of the doctor

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• In a case of patients transfer from
  general/clinical hospital to clinic, with
  interhospital referral and copy of a blue coupon,
  the general/clinical hospital produce an invoice
  by calculationand the same is submitted to the
  clinic that is coding the patient according to
  DRG, with all performed procedures (both, from
  the clinic and from the general/clinical
  hospital)

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• Description of diagnoses and procedures in the
  Hospitals Grouper

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