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All Patient Refined DRGs (APR DRGs)

NYS Medicaid's newly adopted APR-DRGs are significantly more complex than previous payment systems. Hospitals need to ensure that they are capturing the proper SOI to ensure accurate reimbursement. The APR grouper logic and relative weights are very different than the familiar MS and AP DRGs. There are new areas where improved clinical documentation and coding can lead to higher SOI levels. Coding strategies that were effective under other DRG grouping systems need to be updated. For example:

  • The designation of diagnoses as CCs / Major CCs under both MS DRGS and AP DRGs is not related to or consistent with the Severity of Illness (SOI) levels assigned to diagnoses under APR-DRGs.

  • Many diagnoses that impact SOI were not considered CCMCCs under the previous AP and MS DRG systems.

  • It is the cumulative impact of multiple codes which will increase SOI.

  • APR-DRGs each have 4 distinct severity of illness (SOI) levels that drive reimbursement. Complete and specific documentation is more important than ever to capture the multiple diagnoses needed to achieve a high SOI.

  • Most hospitals did not focus their documentation improvement efforts on services like pediatrics, uncomplicated deliveries and normal newborns because there was minimal opportunity to affect DRG assignment under the AP and MS DRG systems . However, these services tend to have high Medicaid utilization and now have increased potential for improvement under APR-DRGs.

Contact us today to customize your APR-DRG strategy.

PCS is now offering a Complimentary Customized APR-DRG Hospital Profile. To view a sample chart about Severity of Illness Distribution from this profile click here.

How Do You Compare to Top Performing Hospitals?

We have compared hospitals' SOI mix by the most important product lines to top performing peers. Reporting secondary conditions and assigning the correct diagnosis codes is critical to accurate DRG and SOI assignment. Higher SOIs lead to higher reimbursement.

Our team will identify your opportunities - even in areas not traditionally the focus of your previous Clinical Documentation Improvement Initiatives. Understand your current DRG and SOI mix with:

  • Data Analysis, Departmental Review, and Reimbursement Modeling
  • Coding and Billing Audits
  • Operational Assessments

Once you understand how APR-DRGs affect your hospital, PCS will help you:

  • Establish targets and focus areas
  • Educate your team
  • Monitor your progress

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