Changes in Medicare Diagnosis Related Group (DRG) system for primary and revision hip and knee replacements and their implications on hospital reimbursement

Current Orthopaedic Practice

Volumn 21, Issue 2, 2010, Pages 120-125

  Kim, Sunny ^a   Meehan, John P ^a   Jamali, Amir A ^a  

^a UNIVERSITY OF CALIFORNIA   (United States)

Author keywords

Medicare; Reimbursement; Total hip arthroplasty; Total knee arthroplasty

Indexed keywords

COST BENEFIT ANALYSIS; COST EFFECTIVENESS ANALYSIS; COST OF ILLNESS; DISEASE SEVERITY; FINANCIAL MANAGEMENT; HEALTH CARE COST; HEALTH CARE NEED; HEALTH CARE QUALITY; HEALTH CARE SYSTEM; HEALTH INSURANCE; HIP ARTHROPLASTY; HOSPITAL ADMISSION; HOSPITAL CARE; HOSPITAL COST; HOSPITAL SERVICE; HOSPITALIZATION; HUMAN; KNEE ARTHROPLASTY; MEDICAL CARE; MEDICAL DOCUMENTATION; MEDICAL INFORMATION SYSTEM; MEDICARE; ORTHOPEDIC SURGERY; PATIENT CODING; PRACTICE GUIDELINE; PRIORITY JOURNAL; REIMBURSEMENT; REOPERATION; REVIEW; SURGICAL RISK;

EID: 77952265111     PISSN: 19407041     EISSN: 19417551     Source Type: Journal    
DOI: 10.1097/BCO.0b013e3181d0c14e     Document Type: Review

References (23)

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2. Centers for Medicare and Medicaid Services. Top 31 elective inpatient hospital DRGs, Fiscal Year 2006. Available at: http://www.cms.hhs.gov/ HealthCareConInit/02-Hospital.asp#TopOf Page. Accessed February 20th, 2009.
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5. Kurtz S, Mowat F, Ong K, et al. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am. 2005; 87: 1487-1497.
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8. Agency for Health Research and Quality. Cost-to-Charge Ratio Files. Available at: http://www.hcup-us.ahrq.gov/db/state/cost tocharge.jsp. Accessed February 13th, 2009.
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10. Grimaldi PL, Micheletti JA. Diagnosis Related Groups: A Practitioner's Guide. Chicago: Pluribus press; 1983.
11. Social Security Administration. Social Security: A Brief History, • SSA Publication No. 21-059. Available at: http://www.ssa.gov/history/ pdf/2007historybooklet.pdf. Accessed June 23rd, 2009. This document, listed under the official website of the US social security administration, explains the development of social security, key dates in the history of social security, and amendments to social security recommended by Greenspan commission. The amendments to social security, signed into law (Public Law 98-21) on April 1983, established a new system of inpatient prospective payment for hospital services under Medicare. Under the new inpatient prospective payment system, patients were grouped by the DRG system for reimbursement purposes.
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13. The Medicare Payment Advisory Commission (MedPAC) Payment Basics: Hospital Acute Inpatient Services Payment System. Available at: http://www.medpac.gov/documents/MedPAC-Payment-Basics-08-hospital.pdf. Accessed June 15th, 2009.
14. Centers for Medicare and Medicaid Services. Acute Inpatient PPS. Available at: http://www.cms.hhs.gov/AcuteInpatientPPS/01-overview. asp#TopOfPage. Accessed June 8th, 2009.
15. Centers for Medicare and Medicaid Services. Intermediary-Carrier Directory. Available at: http://www.cms.hhs.gov/ContractingGeneralInformation/ Downloads/02-ICdirectory.pdf. Accessed February 1st, 2009.
16. Centers for Medicare and Medicaid Services. Details for FY 2009 Final Rule Historical DRG Weight File Available at: http://www.cms.hhs.gov/ AcuteInpatientPPS/IPPS2009/list.asp#TopOf Page. Accessed June 8th, 2009.
17. Steinwald B, Dummit LA. Hospital case-mix change: sicker patients or DRG creep? Health Aff. 1989; 8: 35-47.
18. Bozic KJ, Katz P, Cisternas M, et al. Hospital resource utilization for primary and revision total hip arthroplasty. J Bone Joint Surg Am. 2005; 87: 570-576.
19. Centers for Medicare and Medicaid Services. Rules and Regulations, Federal Register, Vol 70, No155. Available at: http://www.cms. gov/Quarterlyproviderupdates/downloads/cms1500f.pdf. Accessed February 1, 2009.
20. Centers for Medicare and Medicaid Services. Medicare Program; •• Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Final Rule. Rules and Regulations, Federal Register, Vol 72, No 162 (August 22, 2007). Available at: http://edocket.access. gpo.gov/2007/07-3820.htm. Accessed June 13th, 2009. This federal register provided the final rule of Medicare Severity DRG (MS-DRG) classification system for the inpatient prospective payment system (IPPS). To more accurately reflect the degree of hospital resource use in reimbursement, CMS split the DRGs into three different categories based on the severity of illness. Based on this refined DRG system, Medicare payments to hospitals that treat sicker patients have been increased. In this document, information on diseases and disorders of the musculoskeletal system and connective tissue is found under Major Disease Category 8.
21. Centers for Medicare and Medicaid Services. Table 6J-CC List: Complete Complication and Comorbidity (CC) List for the MS-DRGs. Available at: http://www.cms.hhs.gov/AcuteInpatientPPS/FFD/itemdetail.asp?filterType= none&filterByDID=0&sortByDID=2 &sortOrder=descending&itemID= CMS1213990&intNumPerPage= 10. Accessed July 19th, 2009.
22. Centers for Medicare and Medicaid Services. Table 6I MCC List: Complete Major Complication and Comorbidity (Major CC) List for the MS-DRGs. Available at: http://www.cms.hhs.gov/Acute-InpatientPPS/FFD/itemdetail.asp?filterType= none&filterByDID= 0&sortByDID=2&sortOrder=descending&itemID= CMS1209835 &intNumPerPage=10. Accessed July 19th, 2009.
23. Centers for Medicare and Medicaid Services. Medicare Program; •• Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Final Rule. Rules and Regulations, Federal Register, Vol 73, No 161 (August 19, 2008). Available at: http://edocket.access.gpo.gov/2008/ pdf/E8-17914.pdf. Accessed June 25th, 2009. This federal register provides information about recent adjustments in MS-DRG system. This document explains that some hospital acquired conditions (HAC) removed from the MS-DRG assignment unless they were present on admission (POA). For instance, diabetic coma, surgical infection following certain orthopaedic surgeries, deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement surgeries will be considered as preventable.