Grouping rules in case the lab or clinical physiology functions’ tests have been performed
|Target version:||Expert Group 2016|
|MDC:||GEN||Owner / responsible:||National organisations|
|Target Grouper:||Old forum status:|
This is a note to address an issue related to DRG grouping of outpatient cases when certain lab or clinical physiology functions’ tests have been performed during the outpatient visit.
There is separate classification in Finland for those tests and it is attached in appendix 1 (in column “O” the names of the codes are in Swedish which helps to understand the content of the codes).
The codes are not taken into account in grouping logic at the moment (as they are not part of NCSP classification) which means that the case will be assigned to 900-series DRG (short therapy w/o significant intervention) based on main diagnosis. Nevertheless, some tests are remarkably expensive and have impact on cost of the outpatient case compared to ones where no lab or clinical physiology functions tests are performed. This, in turns creates heterogeneity in those DRGs and is not in line with main principles of DRG system.
E.g. In case of high-risk pregnancy when the chromosome defect is concerned there is used blood test (NIPT-Non Invasive Prenatal Test) of pregnant woman to diagnose it. As main diagnosis one of the subcode of Z36 (Antenatal screening) is used. No intervention code. The case is assigned to DRG 914O (Pregnancy, childbirth and puerperium, short therapy w/o significant procedure).
Same concerns the cases with e.g. electroencephalography (EEG), polysomnography (PSG) and other tests when the high(er) costs are concerned.
We would like to discuss the issue in expertnetwork and learn from other countries whether or not this is the issue in their country from grouping point of view and if so, how it has been dealt with.
#2 Updated by Mats Fernström over 5 years ago
- File SWE2016-SOS-PR1-Short.xlsx added
Mats Fernström, NPK, Sweden 2016-02-04
At first some Swedish history. Up till around year 2005 we had only the surgical classification, KKÅ, (Klassifikation av Kirurgiska Åtgärder) which is very similar to NCSP. Year 2006 we got also a classification of medical procedures, KMÅ, (Klassifikation av Medicinska Åtgärder) with approximately 2 600 new procedure codes. KKÅ and KMÅ were subsequently joined under a collective name, KVÅ, Klassifikation av vårdåtgärder (classification of health care procedures).
When we got all the new codes for medical procedures we introduced 234 new outpatient DRGs that replaced the 48 DRGs in the former 800 and 900 series. 150 of the 234 new outpatient DRGs were procedure related and the rest 84 were conservative groups. Last year we increased the number of outpatient DRGs with another 120 conservative groups with the same grouping logic as the inpatient conservative groups.
I think we had a somewhat misdirected ambition when we created so many procedure related groups. Many of them contain rather few cases and the average costs don’t differ very much between some of them.
The file SWE2016-SOS-PR1-Short.xlsx shows the present situation. All rules in the table DRGLOGIC that have a procedure property with the letter V in the columns PROCPRO1 or SECPROC1 leads to the special Swedish outpatient DRGs. What procedure codes that have the current procedure property (with the letter V) can then be found in the table PROC1. Conversion from Swedish procedure codes to NCSP+ codes can be done in the table CSP.