DRG's in ASC's

[tgutierrez]

I bill for an ASC in Arizona but have a patient that uses Oklahoma Workers comp benefits and they are requiring us to bill with DRG's. I have only done physician and ASC billing and am not familiar with DRG's. I did find the Oklahoma Workers comp specific DRG's but I don't know where they go on the claim and I'm not even sure how to pick the DRG's. I thought they were specific to the Diagnosis. Is this incorrect? Where do the DRG's go on the claim form?

Any information regarding this would be VERY helpful.

Thank you,
Terri

[rmwinder]

I'd call Oklahoma WC if I were you and get some clarification, because DRG's are strictly inpatient related. They are Diagnosis Related Group's. In other words if an inpatient has a certain diagnosis upon discharge, the hospital is paid a set amount, according to the DRG assigned by the coder upon reviewing and coding the chart.

A DRG will supposedly encompass all the things and resources a hospital had to use and do during the patient's stay for that discharge diagnosis. If there are any CC's (complications and comorbities) the coder needs to note that so that the hospital may get more reimbursement. Of course, it all has to be documented. Now there is such a monster as POA's (present on admission) diagnoses...but that's another headache.

ASC's and doctors offices do not code w/ DRG's and there wouldn't be a place on the claim form, only on hospital claim forms.

Hope this helps!

[tgutierrez]

I have called and I even got a website and got the list of DRG's and sure enough, their state law states that ASC's are to bill with DRG's. We bill most of our claims on a UB04, isn't that the same as the hospital claim form? If so, where on this claim form does the DRG go? Do we still bill CPT's and Revenue codes? ARG, I'm not doing any more of these patients.

Thanks for the imput.

Terri

[kevbshields]

There's a spot on the UB for the DRG: field 71, "PPS Code".

The CPT & Rev codes probably do remain on the claim in the appropriate fields. Also, you'll need to calculate your DRG correctly. Be sure you find out what (CMS) year's DRG the OK Work Comp is using . . . that will determine your grouping.

By the way, work comp can create their own rules--regardless of how strange those requests may seem.

Good luck.