Wiki Hospital DRGs

[GretchenC123]

I am an LNC completing a medical record review of a patient who had lumbar fusion/decompression surgery and had terrible complications. I need to do an audit of the billing. Does Medicare pay per DRG even when there are complications and the patient ends up in the hospital for a lengthy period? If so, how do I determine what the DRGs are? I have an itemized bill that totals over 1 million dollars which I know Medicare did not pay. Any help would be appreciated.

 

[sls314]

Medicare would still reimburse based on IPPS (Inpatient Prospective Payment System). MS-DRG methodology would still apply. There is outlier methodology under IPPS that could potentially provide additional reimbursement depending on the circumstances.

If any of the complications were Hospital Acquired Conditions (HACs), those would be excluded from additional reimbursement.

You'd need to know what MS-DRG was billed by the facility. (Unless you're auditing to determine whether the facility billed the correct MS-DRG, then you'd want to run it through grouping methodology and come up with your own MS-DRG determination.)