DataMetrix DRG Module

Grouper

The DataMetrix Grouper:

• Uses formulas designed to calculate DRG assignments identical to the CMS standards.
• Performs its classifications based on ICD9-CM diagnosis and procedure codes as well as patient demographics.
• Return values include DRG weight and description, the average length of stay for the DRG, the corresponding CMS DRG version used and all diagnosis and procedure codes that were used in calculating the correct DRG.
• Additional messages alert the user to any inconsistencies found during the DRG assignment process.

Pricer

The DataMetrix Pricer works seamlessly with the DataMetrix Grouper by utilizing the assigned DRG as the basis for reimbursement. The DRG, along with the National Provider Identifier (NPI) or Medicare number, dates of service, patient discharge status and other pertinent claim information, is used to determine with precise accuracy the CMS mandated claim reimbursement.

Inpatient Claim Edits (Including Medicare Code Edits)

Each inpatient claim is cross-checked against a set of over 4600 Medicare-related and DataMetrix proprietary coding edits to validate consistencies in items such as gender and age specific coding, appropriate use of discharge status, correct usage of primary and secondary diagnosis codes and many others.

Benefits

• DataMetrix DRG Module automatically chooses the correct version to use based on the discharge date of the claim
• DataMetrix DRG Module can be used as a standalone or integrated function with your current claim system
• Calculations are updated in accordance with CMS schedules
• Minimizes user error

DataMetrix performs two services:

• DRG Pricing
• DRG Validation

DRG Pricing: An automatic grouping, editing, and pricing of claims. On a post-payment basis, this will group, edit, and price >3,000 claims per minute. On a pre-payment basis, it will insure proper DRG payment.

DRG Validation: The process of identifying likely claims that are miscoded; obtaining medical records verifying and or re-assigning diagnosis and procedure codes or other data elements. This process is performed by certified hospital coders.

What makes DataMetrix different?

Our DRG and APC edits identify and investigate:

• Discharge status
• Automated pricing engine not updated timely
• Incorrect DRG/APC version being applied
• Improper interpretations of Medicare website
• Incorrect manual calculations
• Incorrect DRG/APC grouping
• Correct pricing for Medicare Advantage (HMO paid claims)
• Out of date fee schedules
• Post acute transfers
• Late charges
• System defaulted payments

Any and all of these may impact the pricing and accuracy of payments. Our results are documented and explained to the provider. When agreement is reached, and signoff obtained, DataMetrix recovers overspent dollars that come back to the Health Plans.