Bundle Example for JSON Display for DRG Claim about price-transparency-guide

[dawndrake58]

There are several issues we find with DRG pricing, and how to fit into the allowed format.

1. How is severity listed.
   Example: DRG 001 has severity options of 1 and 2. Should this be listed as 001.1 and 001.2?

2. Is is allowed to list the DRG payments as FFS type with the DRG billing type as the corresponding rate? If using bundle, listing every Diagnosis (ICD) code and Surgical Code that COULD be in that DRG (as well as many others) is something that is generally standard.

3. Yes, please tell us if DRG must be bundled, and if so please provide an example.

[dawndrake58]

Not yet. We are looking at FFS for now as our DRG vendor stated this is how other payors are categorizing DRG (and because the specific ICD codes are not available via their tool).

[Labouv0506]

Just a question, as this is prospective and you do not know the members severity.....should we not be choosing a case, be it best or worst case and demonstrating that.
My thought, patient severity is not known (as patient specific) should we not just note that additional funds can be considered and paid based on patient condition/severity at time of service.

[arichman05]

Has anyone received an answer on how to categorize DRG payments? FFS vs. Bundle?

[clovis517]

In my opinion for APR-DRG the . separator should be used as you suggest, 001.1, and DRG should be recorded as FFS because 1. The Visit+DRG constitutes the "service" 2. It isn't possible to represent full blown grouper logic in the bundle schema, it isn't a simple many:1 relationship 3. The intent of the bundle object is to communicate what service lines will and will not be included in the bundle. DRG is whole claim pricing so this is known, all services included. 4. The bundling logic is available elsewhere, no value add in misrepresenting it in the MRF.