DRGs are assigned by a "grouper" program that gathers claim information based on ICD. diagnoses, procedures, age, sex, discharge status, and the presence of complications or. comorbidities. All these factors are used to determine the appropriate DRG on a case by case. basis.
Approved List of Surgical Procedures
For Medicare patients, you cannot perform just any procedure in the ASC setting. Medicare has an “approved” list of procedures for the ASC that CMS has determined not to pose a significant safety risk, and that is not expected to require an overnight stay following the surgical procedure. The list of approved procedures is based on the criteria:
- They are NOT emergent or life-threatening (for example, a heart transplant or reattachment of a severed limb).
- They CANNOT be performed safely in a physician’s office.
- They can be elective.
- They can be urgent.
Procedures also do not involve major blood vessels or result in major blood loss, and cannot involve prolonged invasion of a body cavity.
Medicare publishes this list of covered procedures annually. Updates are published quarterly, or as necessary. The file consists of two addenda listing approved surgical procedures and covered ancillary services.
Medicare Claims Submissions
There is a separate set of billing rules for ASCs. While some issues may be addressed by CMS, most billing guidelines are best obtained from your local carrier or intermediary. Some carriers/intermediaries issue very detailed guides (e.g., Trailblazer), while others may simply provide a list of links to the CMS website (e.g., Empire).
To reiterate, an ASC must not report separate line items, HCPCS Level II codes, or any other charges for procedures, services, drugs, devices, or supplies that are packaged into the payment allowance for covered surgical procedures. The allowance for the surgical procedure itself includes these other services or items.
CMS does, however, strongly encourage billing for drug and biologicals that are eligible for separate payment. ASCs should report supplies with the correct HCPCS Level II code and correct number of units on the claim form.
This overview will help you know what’s most important when coding and billing in the ambulatory surgery center (ASC) setting.
www.aapc.com
July 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
AAPC offer this as well:
https://www.aapc.com/codify/icd-10-...ows users to,Stay, Procedure Type, Post Acute
FAC also has this:
Diagnosis-Related Group (DRG) Codes
Diagnosis Related Group codes - DRG Codes - Diagnosis-related group (DRG) is a system to classify hospital cases into one of approximately 500 groups, also referred to as DRGs, expected to have similar hospital resource use, developed for Medicare as part of the prospective payment system.
www.findacode.com
Notice Regarding Upcoming Releases of the MS-DRG Grouper and MCEThe current versions of the MS-DRG Grouper and MCE use Java software and are currently based on Java version 8. Support for Java version 8 will end by November 2026. Hospitals and their software vendors who implement these...
www.cms.gov
