KKPMT 6 15 DRG-CASE-MIX PENENTUAN DIAGNOSES PULANG (ICD-WHO) Disusun oleh dr. Mayang Anggraini Naga (Revisi 2016)

DESKRIPSI Untuk mencegah kerugian akibat tertahannya atau keterlambatannya penyelesaian kode diagnosis(es) pulang pasien sebagai penentu besaran biaya tagihan rawat asuhan medis dan pelayanan rumah sakit, pengkode harus bekerja secara: - presisi, - akurat dan - tepat.

KOMPETENSI Mampu mengerti - Penentuan Kode diagnoses tanpa - Arti diagnosis(-es) dalam penentuan biaya rawat. - Cara memilih diagnosis final pasien - Cara penyelesaian kode diagosis(-es) - Cara mencegah kerugian yang bisa terjadi akibat penentuan diagnosis pulang yang salah - Penentuan Kode diagnoses tanpa Fraud (penipuan) atau Abused (penyalahgunaan)

WHO Problem pada Saat Menentukan Discharge Diagnose Kesulitan sering timbul: (1) Pada saat membedakan antara: “Principal diagnose(is)” dari “Most Significant Diagnose” yang terkadang bisa sama.

digunakan bersama dan tidak jelas perbedaannya dengan (Lanjutan) (2) Apabila istilah “Primary” dan “Secondary Diagnose” digunakan bersama dan tidak jelas perbedaannya dengan “Principal” dan “Most Significant” atau “Additional Diagnoses”

Adakalanya: Diagnosis Pokok (Principal) bukan Primary Diagnose (utama) Mengapa? Diagnosis pokok menjadi alasan kuat untuk pasien admisi masuk rawat namun: Bisa juga bahwa akhir rawat ternyata memang diagnosis pokok ini adalah = “Primary Diagnose”

Panduan Penentu Diagnosis Pokok Telaah seluruh RM/HR  cari diagnosis pokok Diagnosis pokok bisa cocok dengan admitting diagnosis (diagnosis masuk) atau problem Mungkin saja komplikasi yang sudah ada waktu admisi adalah diagnosis pokok Diagnosis yang ditulis di urutan teratas oleh dokter belum tentu diagnosis pokok.

DIAGNOSES LAIN-LAIN PRINCIPAL DIAGNOSIS The Diagnosis of the Condition Established after Study to be the Chiefly responsible for the Occasioning the Admission of the Patient to the Hospital for Care

PRIMARY DIAGNOSIS Tradisional digunakan pada DATA VITAL STATISTIC RECORDS Mengacu ke Underlying Condition atau CAUSE of DEATH atau MORBIDITY “Primary” sering dicampuradukkan dengan “Most Significant”  dan belum ada definisi universal yang memberi batasan pengertian kedua istilah ini!

“PRINCIPAL” and “Other” Diagnosis Tentukan terlebih dahulu penggunaan istilah “Principal” dan “Other” dengan tujuan utama: untuk menjelaskan: EPISODE PERAWATAN RUMAH SAKIT juga “Additional” lebih disukai daripada “Secondary”  ini tidak memberi kesan seolah ada diagnoses yang kurang penting secara klinis.

DISCHARGE DIAGNOSIS (Diagnose pulang/selesai satu episode rawat) - SATU dari DIAGNOSES yang TEREKAM yang dipilih setelah AKUMULASI DATA Selama EPISODE PASIEN DIRAWAT/MEMPEROLEH ASUHAN MEDIS  DIKAJI Disebut: “FINAL DIAGNOSIS” - LIST OF DISCHARGE DIAGNOSES = seperangkat DAFTAR DISCHARGE DIAGNOSES Seorang PASIEN RAWAT INAP

OTHER DIAGNOSIS A DIAGNOSIS, other than Principal Diagnosis that describes a condition for which a patient receives treatment or which the physician considers of sufficiencies to warrant inclusion for investigative medical studies

An Additional Diagnosis that Describes a Condition COMPLICATION An Additional Diagnosis that Describes a Condition arising after the beginning of hospital observation and treatment and modifying the course of the patient illness or the medical care required

Komplikasi memiliki art sempit: Apabila: It describes an Undesired Result or Misadventure in medical care of hospital patient. such as: - decubitus ulcer - post-op hemorrhage - adverse effect of medicinal agent - hospital acquired infection (nosocomial-infection) - surgical emphysema, etc.

Komplikasi memiliki arti luas: Apabila: It denotes any condition concurrent with the condition described in the Principal Diagnosis regardless of the time of it’s onset.

Most Significant Diagnosis The one diagnosis, often but not necessarily the Principal Diagnosis that describes the most important or significant condition of a patient in term of its implications for his/hers health, his/hers medical care, his/hers use of the hospital

Asuransi Kesehatan membedakan secara tegas antara: COMPLICATION: Complication is a condition that arises during the hospital stay that prolongs the patient’s LOS by at least ONE day in 75% of the cases COMORBIDITY Comorbidity is a pre-existing condition that will, because or it’s present with a specific principal diagnosis cause  an increase in the patient’s LOS by at least ONE day in 75% of the cases.

CONTOH: Pasien A: 1. Appendicitis acuta  rawat untuk pembe- dahan  terlaksana 2. D. Mellitus  co-morbiditas 3. Emphysema pulmonum  gangguan kronik 4. Luka operasi  tidak menyembuh sempurna  memperpanjang LOS pasien 1 = Princ. = Most sig. diag. 2 dan 3 = Additional diag. 4 = complication

CONTOH: Pasien B: Fracture femoris dextra MCI acute, anterior wall  timbul saat dirawat  LOS >> dan menjadi alasan terapi selanjutnya 1. = Princ. diag. 2. = Most. Sig. diag. (walau sebagai additional diag. terhadap keadaan pada 1)

CASEMIX-ADJUSTED = Statistics where the effects of variations in case-mix have been taken into account.

CASEMIX-ADJUSTED COST PER INPATIENT = The total cost of provision of inpatient care, divided by total inpatients treated; and adjusted to take account of the actual mix of patients treated and differences in the mean costs of Casemix Classes

CASEMIX-BASED FUNDING = A method of funding similar (and in some circumstances identical) to output-based funding. Involves funding of the health care products of health care delivery units, where the products are categorized using CASEMIX CLASSIFICATION.

TASK WHERE PATIENT CLASSIFCATION CAN HELP Deciding whether re-admission rates are abnormally high Deciding whether too many or too few pathology tests are being ordered Finding and fixing problems of poor outcome for rehabilitation patients Designing benefits structures in private insurance

Deciding how resources should be allocated between public hospitals (Cont.-) Deciding how resources should be allocated between public hospitals Allocating funds between hospital departments Planning bed and staff numbers for new hospital Investigating whether the nurse staffing mix needs to be changed.

USES OF PATIENT CLASSIFICATION Patient classifications are useful because they help us to find differences in: - outcome, - quality, or cost of care. By understanding the differences, health care professional find opportunities to make health care more effective. Casemix seeks to improve classification of patients care episodes and put them to better use.

3 (three) FEATURES OF CASEMIX Clinical meaning (patients in the same class should have clinical similarities) The episodes in a class should involve similar kinds of; - presenting problems, - treatment methods and outcomes. It is not sufficient merely to ensure that each class contains episodes which are similar in cost. Casemix is designed to ensure every class makes sense to clinicians.

CLASS A class defined as “patients who were in hospital for over 20 days” might contain episodes which are similar in terms of resource used, but it has little clinical meaning, because there are many different reasons for long stays (major trauma, need for rehabilitation, social problems which delay discharge)

FEATURES OF CASEMIX (CONT.-1) Resource use homogeneity (patients in the same class should cost roughly the same treat). Classes is designed in such a way that episodes which required similar levels of resource are assigned to the same class. (Is defining classes by surgical and medical is better than forming them by age?)

FEATURES OF CASEMIX (CONT.-2) 2. In the real world, many more patient care episodes and many more attributes, (such as diagnoses, functional abilities, and type of admission) must be considered.  apply statistical methods to find and evaluate all the options  Finding rules which define the classes in such a way that episodes in the same class are similar in terms of resource use.

FEATURES OF CASEMIX (Cont.-3) The right number of classes (neither too few or too many) (optimal numbers of classes) It is difficult to know how many classes of patient care episodes there should be. Too many classes will have too few observations to allow conclusions to be drawn. Then it would be impossible to know whether a hospital is really different, or whether analyses are merely showing the kind of variability which is normal in small samples.

FEATURES OF CASEMIX (Cont.-4) On the other hand there should not be too few classes. If large numbers of dissimilar cases are placed in the same class, real differences between doctors, nurses, hospitals and so on will be concealed and clinical meaning will be lost.  A compromise is needed.  A statistical methode is needed.

CONTOH: pemanfaatan Case-Mix Minnesota Case Mix (Facility Manual for Case Mix Classification) March 21, 2003 Case Mix” is a means of classifying care that is based on the intensity of care and services provided to the resident) (adalah cara pengklasifikasian asuhan berbasis intensitas asuhan dan tipe pelayanan yang diselenggarakan bagi pasiennya) (Minnesota memiliki 34 klasifikasi case-mix berserta besaran tarip pembayarannya, penalty dan kegagalannya).

Undang-undang negara bagian (USA) mengatur CONTOH: Minnesota …. Undang-undang negara bagian (USA) mengatur bahwa semua fasilitas perawatan menagih pasien yang bayar sendiri dan pasien asuransi (Medicaid) berdasarkan tarif pelayanan yang sama berbasis klasifiaksi case-mix-nya. Artinya:menggunakan “equalization” rate dan mengharuskan semua pasien dalam fasilitas perawatan ditagih dengan tarif yang sama bagi asuhan dan pelayanan yang sama.

CASEMIX - DRGs The size of database depends on the number of patients care episodes which are to be analyzed using the classification.

CASEMIX - DRGs (Lanjutan-1) The extended use: a classification with few classes might be ideal for some strategic management purposes, but less so for a private hospital which is dependent for its financial survival on very precise description of it casemix.

CASEMIX - DRGs (Lanjutan-2) Many assumed there is only one casemix classification. DRGs is the most used casemix classification in the last decade  the use of DRGs for resource allocation deserves special attention.  trend is towards a wider range of uses of many more casemix classifications

A MORE PRECISE STATEMENT ABOUT CASEMIX CASEMIX IS part of a science approach to producing good information about health care IT FOCUSES ON building useful classifications of patients care episodes AND making good use of patient care classifications to manage health care.

A MORE PRECISE STATEMENT ABOUT CASEMIX (Lanjutan) Casemix has to be complicated if it is to help resolve real problems. There would be little sense in simplifying casemix ideas and tools so much that they would no longer be relevant to the real world. Their complexity merely reflects the nature of health care, and if used properly they make the world less, not more, confusing.

Requirements for Case-mix System (1) Accurate diagnosis - Primary Diagnosis * Principle Diagnosis - Main Reasons for admission - used to assign MDC - Secondary Diagnosis * Complication * Co-morbidities

Requirements for Case-mix System (2) Costing Data * Charges * Step-down costing * Case-Mix costing * Acivity based costing - for selected conditions

Requirements for Case-mix System (3) Classification System * Disease Classification - ICD-10 * Procedures Classificaion - Surgical procedures - Non-surgical procedures

Requirements for Case-mix System (4) Health Management Information System - Properly established: hardware & software - Trained manpower: trained coders - Proper record keeping - Budgets to maintain HMIS

Requirements for Case-mix System (5) Support from Hospital Management - Quality Assurance Programme - Medical Audit - Hospital Benchmarking - Use Case-Mix System - Appropriate feed-back to Clinicians - Negotiates funding with potential funders.

DRGs (Diagnosis-Related Groups) Ini adalah klasifikasi pasien rawat. DRGs are designed to catagorise acute inpatient episodes, but CASEMIX classifications have been developed for other kinds of episodes: - outpatients, - nursing home care.

The first step involves looking at the principle diagnosis DRG (Lanjutan-1) The first step involves looking at the principle diagnosis = the diagnosis or condition established after study to be chiefly responsible for the patient’s admission to hospital. The significant procedure performed and check the kind of procedure.

Taking account on the patient’s age (children or old) DRG (Lanjutan-2) Taking account on the patient’s age (children or old) (4) COMPLICATIONS or COMORBIDITIES (5) Types of discharge.

AN- Casemix Dictionary The Australian Casemix Dictionary (Department of Human Services and Health): Diagnoses clusters: A classification system developed in the early 1970s. Which only made use of diagnoses. (AVGs = Ambulatory Visit Groups)

AHIMA & AN-DRG Diagnosis chiefly responsible for services provided (out patient) = The diagnosis, condition, problem, or reason for encounter/visit that is chiefly responsible for the services provided. If a definitive diagnosis has not been established at the end of the visit/encounter, the condition should be recorded to the highest documented level of specificity (such as symptoms, signs, abnormal test results, or other reason for visit).

AHIMA & AN-DRG (Lanjutan) The main variables which influence AN-DRG assigment include: Principal diagnosis (ICD-CM code) Procedure codes (ICD-CM code) Secondary diagnoses (ICD-CM code) Age and gender Birth weight (neonatus only) Dischage status

AN-DRG PDX is used to assign the episode of care to one of 23 Major Diagnostic Categories (MDCs) MDCs correspond generally to the main organ systems of the body. The following specific variables are exceptions: - Age less than 29 days - Principal diagnosis which is a specific neonatal disorders - Principal or secondary diagnosis of HIV - Liver transplant - Bone marrow transplant - Principal diagnosis of multiple trauma - Tracheostomy procedure.

AN – DRGs (Lanjutan-1) Medical or surgical partition according to whether a significant operating room (OR) procedure has been performed. It is to be noted that not all procedures are considered significant OR procedures. 3. Sub grouping based on the precise surgical procedure performed or, for medical patients, the precise condition designated as the principal diagnosis.

4. Final assignment to a DRG is usually made AN – DRGs (Lanjutan-2) 4. Final assignment to a DRG is usually made by age or the existence of a complicating diagnosis and/or comorbidity (CC)* 5. A substantial complication or comorbidity (CC) is defined as a condition that because of its presence with a specific principal diagnosis, would cause an increased in the length of stay by at least one day.

PRINCIPAL DIAGNOSIS The diagnosis or condition established after study to be chiefly responsible for occasioning the patient’s admission to hospital. (AN-standard definition. One of the two most important variables used to define AN-DRG classes)

Includes complications and comorbidities. SECONDARY DIAGNOSES Any condition additional to the principal diagnosis which affects patient care by - requiring clinical evaluation, - therapeutic treatment, - diagnostic procedures, - extended LOS, or increased - nursing care or monitoring. Includes complications and comorbidities.

treatment rather than for diagnostic or exploratory purposes. PRINCIPAL PROCEDURE The procedure performed for definitive treatment rather than for diagnostic or exploratory purposes. In the context of assignment to an AN-DRG class, selection of one procedures as principal is not necessary. PROCEDURE A therapeutic intervention. Procedures are coded using ICD-9-CM. One of the two most important variables used to define DRG classes.

PROCEDURE HIERARCHIES List of procedures in order of their relative costliness. Assignment to an AN-DRG is on the basis of the highest ranking procedure only, where two or more were undertaken. Ranking is determined by the computer software (the Grouper). PROCEDURE REVIEW A type of utilization review which involves assessing the patient’s need for diagnostic and therapeutic procedures.

PROSPECTIVE PAYMENT SYSTEM PPS A type of output-based funding formula, whereby health care providers (usually hospitals) receive predetermined payments for each episode of care defined by casemix classes. (Usually DRGs) The term was first used for US Medicare’s DRG-based payment system for hospitals.

PATIENT CLASSIFICATION SYSTEM (AN) (Cont.-) PATIENT CLASSIFICATION SYSTEM (AN) (Private Hospital) A simple casemix classification for inpatient episodes which is used to bill for all services excepting critical care and operating rooms.