DRG and Weight Calculation

A diagnosis-related group (DRG) is a case-mix complexity system implemented to categorize patients with similar clinical diagnoses. Medical Severity Diagnosis Related Group (MS-DRG) is a classification system used to categorize patients into groups based on their diagnoses, procedures performed, age, gender, and other factors. MS-DRGs are determined based on the ICD-10 primary diagnosis codes assigned to a case, including Complication and Comorbidity (CC)/Major Complication and Comorbidity (MCC).

QDI generates two different MS-DRG codes, descriptions, and relative weights for each case to assist CDI Specialists with their case management and help them optimize patient care.

To see the DRG for an individual case, navigate to the case from the QDI Cases view, and click on the DRG tab at the top. You will see a Working DRG, which was computed when the case was created. From the DRG tab of an individual case, you can find a Working DRG. After a case has been closed, you also will see a Reviewed DRG. Click on one of them to see details about it to the right.

Working DRG is the DRG allocated to a case upon hospital admission based on the presenting problem or provisional diagnosis. A working DRG is an initial DRG assigned prior to a CDI specialist’s record review and query efforts. If diagnoses are added or procedures are performed during a patient’s hospital stay, the working DRG may change. QDI generates and displays a working MS-DRG and relevant code for all Tendo-generated cases using patient data that your healthcare organization has provided when a case is created, using all of the procedures and diagnoses related to the case. While the case is in progress, the working DRG for the case can change when a new diagnosis or procedure is added or removed (e.g., if the primary diagnosis is changed).

For each Working DRG, you can view the

• Code
• Description
• Relative Weight
• Principal Diagnosis code
• Secondary Diagnoses codes
• Procedure Codes

Reviewed DRG (also called queried DRG) represents the MS-DRG after the CDI Specialist review and query to a Provider. When a CDI specialist closes a case in QDI after the provider query has been agreed to by the provider, diagnoses code from the accepted opportunity conditions are incorporated to generate a new MS-DRG, which becomes the Reviewed DRG. If the opportunity is not accepted, the Recommended Diagnosis code from the case is not incorporated into the Reviewed DRG. This means that on the individual case page, you must first mark an Opportunity Status as Completed, and then mark the Query Status as Query Agreed in order for the opportunity to be used in computing the Reviewed DRG.

Click Close Case. This will mark the case as Closed, and set the date it closed as well as compute the Reviewed DRG.

The diagnosis code from the accepted opportunity condition can now be seen in the Recommended Diagnosis field of the Reviewed DRG section.

For each Reviewed DRG, you can view the

• Code
• Name
• Weight
• Admission Diagnosis
• Principal Diagnosis
• Secondary Diagnoses
• Procedures
• Recommended Diagnosis

For CDI Specialists, MS-DRG may help you optimize your case management.

For CDI Managers, Working and Reviewed MS-DRG comparison can help you understand the impact of your CDI Team. If you need help setting up a report to compare the Working and Reviewed DRGs, contact Tendo Support.