1. Diagnosis Related Groups (DRGs)

2. Diagnosis Related Group
DRG Diagnosis Related Group. A "Diagnosis Related Group" is a payment category that is used to classify patients, especially Medicare patients, for the purpose of reimbursing hospitals for each case in a given category with a fixed fee regardless of the actual costs incurred. A DRG is based upon the principal ICD-9-CM diagnosis code, ICD-9-CM surgical procedure code, age of patient, and expected length of stay in the hospital that will be reimbursed, independently of the charges that the hospital may have incurred

3. DRG OVERVIEW:
The American health care system was quite different than it is today.  Back in the 1950s not everyone had health insurance, mostly those who did had either private insurance or BC/BS (Blue Cross/Blue Shield).  In the 1960s Medicare and Medicaid was created. 
In the 1970s, there was a lot of distrust for the U.S. government including lack of confidence in the American medical system.  There were many without insurance and a great number of companies did not offer health care benefits.  President Nixon created Managed Care Organizations (MCOs), which required companies to provide health insurance for their employees.  
Distrustبي اعتمادي
Reimbursedبازپرداخت
Rendered ارائه
Streamlineساده و موثر كردن
Cut كاهش
Lump مجموعه

4. What really transformed is the way in which inpatient health care would be reimbursed in the 1980s.  Health care costs were out of control.  Facilities were being reimbursed for what services they provided regardless of cost (fee for service or time rendered) and there was no incentive for them to streamline costs.  Congress implemented the UB-82 (now UB-92) to create one claim form for all insurance agencies for inpatient services.  
The DRG system was created in 1983 to cut costs for Medicare patients.  The DRG system is a patient classification system that groups patients with similar diagnoses and/or procedures into the same category.  The facility is then reimbursed with a lump sum payment based on this category, figuring on average what it would cost to treat a patient with a diagnosis.  Congress also required that facilities have an active Utilization Review and Quality Assurance Department to evaluate the quality of care patients are receiving and how that care is utilized (how much resources are used) to care for the patient.

5. History
In the mid 1970s the Centre for Health Studies at Yale University began work on a system for monitoring hospital utilisation review. Following a 1976 trial of a DRG system, it was decided to base the final system on the ICD-9-CM which would provide the basic diagnostic categories

6. Purpose.
relate a patient’s diagnosis and treatment to the cost of their care
Developed in the United States by the Health Care Finance Administration
DRGs are used for reimbursement in the prospective payment system of US Medicare and Medicaid healthcare insurance systems
DRGs were designed to support the calculation of federal reimbursement for healthcare delivered through the U.S. Medicare system

7. A patient’s principal diagnoses and the procedures they are treated with during hospital admission are used to select the group in the DRG classification that most appropriately describes they overall type of care that has been delivered.
Diagnosis Related Groups (DRG) are a system classifying in-hospital patient cases into categories with similar resource use. The grouping is based on diagnoses, procedures performed, age, sex and status at discharge
Next the group selected is associated with a typical cost. Specifically, DRG funding requires the use of a cost weighting that is applied by the funding agency to determine the actual amount that should be paid to an institution for treating a patient with a particular DRG. The weightings are determined by a formula that is typically developed on a state or national basis.
Fund اعتبار مالي/مالي

8. DRG Structure Major Diagnostic category Medical Surgical split
Complications & Comorbidities
Exclusion list
Structure diagram
DRG Example with severity score
Split انشعاب

9. Major Diagnostic Category Assignment (MDC)
The initial step in the determination of the DRG has always been the assignment to the appropriate MDC based on the Principal Diagnosis
Since the presence of a surgical procedure requires different hospital resources (operating room, recovery room, anesthesia) most MDCs were initially divided into medical and surgical groups

12. Medical Surgical split
All procedure codes were classified based
on whether or not they required the use of
an operating room
Operating room procedures
– Cholecystectomies – Cerebral meninges biopsies – Closed heart valvotomies
Non operating room procedures
– Bronchoscopy – Skin sutures

13. Complications & Comorbidities (CCs)
A complication is a condition which did not exist prior to the admission
A comorbidity is a condition which existed prior to admission
A complication or comorbidity is a secondary diagnosis which would be expected to extend the patient’s length of stay by at least one day in at least 75 percent of patients

14. Major CCs
Within each MDC patients with major CCs (e.g., AMI, CVA, etc.) were assigned to separate DRGs, and as part of the Severity Level process of IR-DRGs
A major complication or comorbidity is a secondary diagnosis which would be expected to extend the patient’s length of stay by at least 3-4 days in at least 75 percent of patients

15. Complication & Comorbidity (CC) Exclusion List
For a principal diagnosis of bladder neck obstruction
– Urinary retention is not a CC
For a principal diagnosis of general convulsive epilepsy
– Convulsion is not a CC

16. DRG Classification - Example
Principal Diagnosis 41091: AMI NOS, Initial MDC 5 Diseases and Disorders of the Circulatory System
Operating Room Procedure 3761:Pulsation Balloon Implant
DRG 110: Major Cardiovascular Procedures with CC or DRG 111: Major Cardiovascular Procedures without CC or DRG 549: Major Cardiovascular Procedures with Major CC
Secondary Diagnosis
1) 25000: Diabetes Mellitus Type II without Complications
- CC : No
- Major CC : No
- DRG : 111

17. DRG Classification - Example 2
Principal Diagnosis 41091: AMI NOS, Initial
MDC 5 Diseases and Disorders of the Circulatory System
Operating Room Procedure 3761:Pulsation Balloon Implant
DRG 110: Major Cardiovascular Procedures with CC or DRG 111: Major Cardiovascular Procedures without CC or DRG 549: Major Cardiovascular Procedures with Major CC
Secondary Diagnosis 1) V434: Blood Vessel Replacement Not Elsewhere Classified (NEC)
- CC : No
- Major CC : No
2) 7100: Systemic Lupus Erythematosus
- CC : Yes
- DRG: 110

18. DRG Classification - Example 3
Principal Diagnosis 41091: AMI NOS, Initial
MDC 5 Diseases and Disorders of the Circulatory System
Operating Room Procedure 3761:Pulsation Balloon Implant
DRG 110: Major Cardiovascular Procedures with CC or DRG 111: Major Cardiovascular Procedures without CC or DRG 549: Major Cardiovascular Procedures with Major CC
Secondary Diagnosis
1) 78551: Cardiogenic Shock
- CC : No
- Major CC : Yes
- DRG : 549

19. Surgical Hierarchy
If multiple procedures are present, the patient is assigned to a single surgical DRG based on a surgical hierarchy within each MDC

20. DRG Structure ساختار كلي DRG از 3 جزء تشكيل شده كه عبارتند از:
PreMDC كه همان قسمت استثناء DRG است
MDC كه همان قسمت اصلي است
ErrorDRG كه از نظر اطلاعات بهداشتي ناقص است. به عبارت ديگر يا اطلاعات موجود در پرونده متناقض يا غير معتبر است و يا تشخيص گزارش شده دقيق و كامل نيست و نمي توان كد DRG خاصي به آن اختصاص داد. اين كدها عبارتند از:
كد 468: اگر بيماري به علتي در بيمارستان بستري شود و به علت ديگري مورد عمل جراحي قرار گيرد،كد DRG468 به آن اختصاص مي يابد.مثلا بيماري كه با تشخيص اصلي نارسايي احتقاني قلب بستري شده اما بدليل التهاب كيسه صفراي رو به پيشرفت ، اقدام جراحي خارج ساختن كيسه صفرا براي وي انجام شده است.
باشد با كد DRG 470 مشخص مي شود.

21. DRG Structure
كد 469: زماني كه تشخيص اصلي انتخاب شده به اندازه كافي دقيق و درست نيست تا بتوان كد خاصي از DRG را به بيمار اختصاص داد از اين كد استفاده مي شود. حتي اگر كدي از ICD براي آن مورد در نظر گرفته شود. مثلا كد در ICD-9-CM نشان دهندة عوارض نامشخص پيش از زايمان، هنگام زايمان و پس از زايمان است. در DRG بايد اطلاعات نشان دهد در كدام مرحله از مراقبت عارضه ايجاد شده است و در صورتي كه مشخص نباشد، كد DRG 469 به آن اختصاص مي يابد.
كد 470: اشتباهات ثبت شده در گزارش هاي پزشكي كه ممكن است بر تخصيص كد DRG اثر بگذارد با اين كد مشخص مي شود. مثلا بيماري كه در گزارشات سن وي 154 سال گزارش شده، در صورتي كه انتخاب كد با سن بيمار بستگي داشته

22. DRG assignment
The first step in DRG assignment is the classification of discharges by Major Diagnostic Category (MDC). There are 25 MDCs which are essentially primary diagnostic groupings generally based on the body systems, e.g. nervous system (MDC 1), eye (MDC 2), circulatory system (MDC 5), etc. There are some exceptions where the classification by MDC does not follow this pattern, for example MDC 14: Pregnancy, Childbirth, and the Puerperium, MDC 24: Multiple Trauma, and MDC25: HIV Infection.
Following assignment to the MDC, discharges are assigned to the DRG level. Discharges with a surgical procedure performed are assigned to the surgical DRGs where classification is based on the most resource intensive procedure

23. performed. Medical discharges are assigned to a DRG on the basis of the principal diagnosis. Further classification within these groups arise if particular variables, like the presence of complications/comorbidities (ccs), age, or discharge status are found to have a significant influence on the treatment process and/or the pattern of resource utilisation.
Some exceptions to the general approach for DRG classification do exist, for example, discharges receiving liver or bone marrow transplants and discharges with temporary tracheostomies being assigned to DRGs outside of the MDC framework

24. DRG assignment
A DRG is assigned based on the patient's diagnosis (ICD-9-CM coding).  The encoder (also known as the DRG grouper) is a software program developed by CMS that places the patient into a Major Diagnostic Category based on the diagnosis.  
For example:  A patient with a fracture  would be grouped to the Musculoskeletal Major Diagnostic Category.  At this point, the patient is considered a medical DRG.  If the patient has a surgical procedure, then the patient is grouped to a surgical DRG.  The other factors that influence DRG assignment is age of the patient, any complication/comorbidities, and discharge status.  

25. Illustration of DRG-grouping, patient > 17 years
Major diagnosis ICD10 S72.0: Fracture of the collum femoris
MDC 08:
Rheumatic diseases
Surgical procedures No
Yes
Type of surgery
Amputation
NCSP 50
Marrow nailing
Biopsy
Secondary
diagnosis
Yes
DRG 236:
Hip/pelvis
fracture
DRG 213:
Amputations
DRG 211:
Hip/thigh bone
operation
DRG 210:
Hip/thigh bone
operation
DRG 216:
Biopsies
(rheumatic diseases)

26. DRG assignment
كدهاي ICD بر اساس سيستم هاي بدن يا تخصص در گروه هاي تشخيصي اصلي [1] قرار مي گيرند.
افرادي كه پس از عمل جراحي مرخص شده اند در گروه جراحي و كساني كه عمل جراحي نداشته اند در گروه پزشكي قرار مي گيرند.
كساني كه در گروه جراحي قرار مي گيرند بر اساس ميزان مصرف منابع به چند گروه تقسيم مي شوند. بيماراني كه چند عمل جراحي داشته اند، بر اساس پرهزينه ترين جراحي طبقه بندي مي شوند. مثلا اگر اقدام كورتاژ و ديلاتاسيون[2] و خارج كردن رحم[3] بطور همزمان بر روي بيمار انجام شود، چون ذرآوردن رحم نياز به تدابير بيشتري دارد، به عنوان اقدام پر هزينه تر انتخاب مي شود.

27. DRG assignment
كساني كه در گروه پزشكي قرار گرفته اند بر اساس تشخيص اصلي به گروه هاي فرعي مانند نئوپلاسم و... تقسيم مي شوند.
در اين گروه ها بيماراني كه به روش هاي مشابه و توسط متخصصين مشابه درمان مي شوند، در يك گروه DRG قرار مي گيرند.
براي گروه بندي نهايي از تشخيص اصلي، عوارض ، بيماري هاي همراه ، سن بيمار، جنس بيمار و وضعيت هنگام ترخيص (مرده، زنده، پيگيري بعدي) استفاده مي كنند.
[1] Major Diagnostic Category (MDC)
[2] Dilatation & Curettage (D&C)
[3] Hysterectomy

28. Example
بيماري با تشخيص ديابت (شروع در بزرگسالي ) و كوليك حاد شكمي پذيرش شده است. پيگيري هاي بعدي سنگ كيسه صفرا را نشان داده است. براي بيمار خارج كردن كيسه صفرا و جستجوي مجاري صفراوي انجام شده است. ديابت بيمار اغلب مدت زماني كه بيمار در بيمارستان اقامت داشته است خارج از كنترل بوده است.
سيستم بدني درگير، سيستم كبدي- صفراوي و پانكراس بوده است. چون برروي بيمار عمل جراحي انجام شده است، اقدام جراحي محسوب مي شود و هيچگونه عوارض يا بيماري همزمان نداشته است.

29. DRG information for DRG-production and DRG-reimbursement
Trimخالص

31. Payment calculation
پس از مرخص شدن بيمار، پزشك تمامي تشخيص ها و درمان ها را روي فرم مخصوص ثبت مي كند.
سپس كد مناسب ICD-9-CM توسط كدگذار تعيين و ثبت مي شود.
بخش حسابداري بيمارستان فرم صورتحساب را فراهم مي كند كه درآن فرم اطلاعات هويتي بيمار، كدهاي ICD-9-CM و ساير اطلاعات ثبت مي شود.
در مرحله بعد كارگزاران مالي صورتحساب يا ليست مورد نظر را ازجهت خوانا بودن و تناسب كدها و صحيح بودن آنها بررسي مي كنند و بر اساس كدهاي ICD-9-CM كد DRG تعيين مي شود.
هر گروه DRG يك ارزش نسبي دارد كه هزينه كليه خدمات و تجهيزات مصرف شده براي بيمار را منعكس مي كند. هرچه اين ارزش بيشتر باشد منابع بيشتري مصرف شده و هزينه بيمار افزايش مي يابد. ارزش نسبي هر گروه DRG در بيمارستان هاي مشابه يكسان است.
[1] Hospital rate

32. Payment calculation
مقدار پرداخت هزينه بيمارستاني در هر بيمارستان بر اساس عوامل مختلف نظير نوع بيمارستان، جغرافيايي، روستايي يا شهري بودن بيمارستان، اختلاف نرخ دستمزد در نواحي مختلف و ساير عواملي كه بر هزينه تاثير دارند تعيين مي شود ، اين مقدار نرخ بيمارستاني [1] نام دارد كه ممكن است در سالهاي مختلف بر اساس نرخ تورم تغيير كند. قبلا وضعيت آموزشي و تعداد تخت نيز در محاسبه هزينه ها بحساب مي آمد ، ولي امروزه تاثير اين عوامل رد شده است.
لذا هزينه بيماران از حاصلضرب نرخ بيمارستاني در هزينه ثابت بدست مي آيد. به اين ترتيب بيمارستان مبلغ ثابتي را دريافت مي كند ، درصورتي كه هزينه بيمار كمتر از هزينه دريافتي باشد، بيمارستان مي تواند مابه التفاوت را بعنوان سود ذخيره نمايد و بر عكس چنانچه هزينه صرف شده براي بيمار بيشتر از مبلغ DRG باشد، بيمارستان مجبور است خسارات وارده را متحمل شود. اين امر باعث مي شود بيمارستان ها ، بيماران سودمند را انتخاب كنند و از درمان بيماران زيان آور خودداري كنند.

33. CODING AND ITS RELATION TO DRG ASSIGNMENT
Coding is a team approach.  If there is improper documentation the facility, along with the physician, are considered noncompliant in reflecting the patient's true hospital course.  Coding can only be done in an accurate, timely, and ethical manner by using conclusive documentation by physicians.  
It is the role of the coder to go through the whole medical record to locate all the information to accurately code including ethically coding complications and comorbidities.  These conditions can be found in various placed in the medical record.  The medical record needs to be comprehensive, legible, well-documented, and completed in a timely fashion to be compliant.  Lacking any of these will place the facility in danger of being audited, increasing the risk of fraud and abuse.
Noncompliantمخالفۀ در تضاد

34. Inpatient Classification Objectives
Aid in Clinical Management
Provide Equitable Resource Allocation Method
Promote Efficiency & Effectiveness in Managing Inpatient Care
Increase Accuracy in Reporting Workload and Associated Costs

35. Develop a classification system that is the basis for
Hospital Management
Budgeting
Benchmarking
Profiling
Clinical research
Quality reporting
Global comparison
Payment
Profilingنيمرخ نما

36. Level of acceptance and use
DRGs are used routinely in the United States for management review and payment for Medicare and Medicaid patients. Given the importance of reimbursement world-wide, DRGs have undergone ongoing development, and have been adopted in one form or another in many countries outside the USA, including Australia (AR-DRG), Canada (CMG) and countries of Europe and Asia.

37. Classification structure
Patients are initially assigned a code from ICD-9 CM or a clinical modification of ICD-10. ICD clinical modifications are multiaxial systems closely based on the ICD structure. Diagnoses are then partitioned into one of about 25 Major Diagnostic Categories (MDCs) according to body organ system or disease. The aim of this step is to group codes into similar categories that reflect consumption of resources and treatment .The categories are next partitioned based upon the performance of procedures, and on other variables such as the presence of complications and co-morbidities, patient age, and length of stay, before a DRG is finally assigned .There is thus a process of category reduction at each stage, starting from the many thousands of ICD codes to the few hundred DRGs:
ICD  MDC  DRG)

38. Limitations
DRGs and case-mix indices will always only give approximate estimates of the true resource utilisation. For example, should a hospital that is developing new and expensive procedures be paid the same amount as an institution that treats the same type of patient with a more common and cheaper procedure? Should quality of care be reflected in a DRG? For example, if a hospital delivers good quality of care that results in better patient outcomes, should it be paid the same as a hospital that performs more poorly for the same type of patient?
As importantly, those institutions that are best able to create DRGs accurately are more likely to receive reimbursement in line with their true expenditure on care. There is thus an implication in the DRG model that an institution actually has the ability to accurately assemble information to derive DRGs and a case-mix index. Given local and national variations in information systems and coding practice, it is likely that institutions with poor information systems will be disadvantaged.

39. Developments
DRGs are designed for use with inpatients. Accordingly, other systems have been developed for other areas of healthcare. Systems such as Ambulatory Visit Groups (AVGs) and Ambulatory Payment Classifications (APCs) have been developed for outpatient or ambulatory care in the primary sector. These are based upon a patient’s diagnosis, intervention, visit status and physician time.

40. The DRG Handbook, 2003

41. DRG audits
DRG audits may consists of evaluating those DRGs that are incorrectly used.  These audits may also focus on missing diagnoses, missing procedures, and incorrect principal diagnosis selection
For DRG based reviews, cases may be selected in a variety of ways:
• Simple random sample
• High dollar and high volume DRGs
• DRGs without comorbid conditions or complications
• Focused DRGs such as DRG 79 Pneumonia or DRG 416 Septicemia and other high
risk DRGs
• Correct designation of patient discharge and transfer status

42. CPT audits
For physician services, hospital outpatient services, and freestanding ambulatory surgery
centers, audits may focus on the following:
• Evaluation and management services for physician visits
• High volume and/or low volume outpatient surgeries
• Use of CPT modifiers on physician and outpatient claims
• Unlisted CPT codes
• Diagnosis codes on outpatient claims for medical necessity of diagnostic services
• Accurate use of ICD-9-CM and CPT for ambulatory surgery services
Freestandingساده

43. Ten DRGs with the highest rates of upcoding
In its August 1998 report, Using Software to Detect Upcoding of Hospital Bills, the Office of Inspector General lists the following diagnosis-related groups as having the highest rates of upcoding.
87-pulmonary edema and respiratory failure
79-respiratory infections and inflammations with complicating conditions (cc)
144-other circulatory system diagnoses with cc
239-pathological fractures and musculoskeletal and connective tissue malignancy
429-organic disturbances and mental retardation
416-septicemia
475-respiratory system diagnosis with ventilator support
188-other digestive system diagnoses with cc
121-circulatory disorders with acute myocardial infarction and cardiovascular complications, discharged alive
316-renal failure

44. case-mix
DRGs are also used to determine an institution’s overall case-mix. The case-mix index helps to take account of the types of patient an individual institution sees, and estimates their severity of illness. Thus a hospital seeing the same proportion of patients as another, but dealing with more severe illness, will have a higher case-mix index
An institution’s case-mix index can then be used in the formula that determines reimbursement per individual DRG

45. Case mix = (200×6990/.)+(450×1447/1)+(300×134/5)+(50×9363/.) 1000
Case mix calculation
بيماران مراجعه كننده به بيمارستان در يك دوره زماني خاص ( مثلا يكسال) را در نظر مي گيريم و مشخص مي كنيم هر بيمار در چه گروه DRG قرار گرفته است. سپس تعداد بيماران هر گروه DRG را در ارزش نسبي همان گروه ضرب مي كنيم.سپس اين مقادير را با يكديگر جمع كرده و بر تعداد كل بيماران در آن دوره خاص تقسيم مي كنيم. هر قدر عدد بدست آمده بزرگتر باشد، هزينه تمام شده براي هر بيمار بيشتر بوده و بعبارت ديگر بيمارستان خدمات ارزنده تري را ارائه داده است.
مثال: در يك دوره زماني خاص ، 1000 بيمار به بيمارستاني مراجعه كرده اند. 200 بيمار كد 450 ، DRG 90 بيمار كد 89، 50 بيمار كد 410 و 300 بيمار كد 475 را به خود اختصاص داده اند. ارزش نسبي اين كدها به ترتيب 6990/.، 1447/1، 134/5، 9363/. مي باشد. كيس ميكس اينگونه محاسبه مي شود:
Case mix = (200×6990/.)+(450×1447/1)+(300×134/5)+(50×9363/.)
Case mix =2/24

46. Example دو بيمارستان با شرايط زير را مقايسه كنيد.
دو بيمارستان با شرايط زير را مقايسه كنيد.
هر دو 200 بيمار را پذيرش كرده اند.
در هر دو بيمارستان ، تعداد روزبيمار 1200 روز بوده است.
متوسط اقامت بيماران حدود 6 روز بوده است.
ظاهرا راندمان دو بيمارستان يكسان است. اما با بررسي دقيق تر مشخص مي شود در بيمارستان الف نيمي از بيماران با تشخيص فتق كشاله ران با ارزش نسبي 0.5 و نيم ديگر با تشخيص زخم معده پيچيده با ارزش نسبي 1.0 بستري شده اند بنابر اين كيس ميكس چنين محاسبه مي شود:
Case mix = (100×./5+(100×1) = 150
در بيمارستان ب 100 بيمار با تشخيص جراحي باي پس با ارزش نسبي 5.5 وبراي 100 بيمار ديگر پيوند كليه با ارزش نسبي 3.84 انجام شده است. بنابر اين كيس ميكس چنين محاسبه مي شود:
Case mix = (100×5/5+100×3/84)= 934
به اين ترتيب مقايسه كيس ميكس ها نشان مي دهد بيمارستان ب تقريبا 9 برابر بيمارستان الف از منابع مصرف كرده است.

47. OPTIMIZATION AND CASE MIX
The facility is reimbursed based on a mathematical equation which takes into consideration on average what resources has it taken other facilities in treating a similar patient.  The payment also reflects the length of stay.  
Every DRG has a relative weight which influences the payment.  
Accurately coding the medical record to its highest level reports the clinical conditions of the patient.  This optimization process places the patient into the best possible DRG, increasing the facilities case mix and reimbursement by reflecting the appropriate resources used. 

48. OPTIMIZATION AND CASE MIX
Optimization may not be gained if the coder is inexperienced in reading the medical record, understanding disease processes, unable to understand where to look for additional information such as drug usage, tests ordered, etc.  By providing the coder with ongoing education, this increases the chance that increased optimization.  Optimization may also not be possible due to lack or poor documentation and poor team relationships.   
Case mix is defined as the type of patients the hospital treats.  Facilities are very concerned on whether their patients are making them money or do they have a high percentage of patients in which it costs the facility more to treat the patient then what they are being reimbursed for.  

49. Case-Mix System is very appropriate especially in justifying the usage of optimum resources in tertiary care hospitals which admits more severe cases. At present, the allocation of resources to hospitals are among others based on the number of beds and previous resource utilization without considering efficiency and thus did not contribute to the improvement of hospital efficiency. Case-Mix System also facilitates in the implementation of quality enhancement programm in line with it original objective of classification. Information on patients’ treatment such as length of stay helps in identifying differences in treatment and problems in quality of patient care so it can be highlighted and managed immediately. Hospitals are also encouraged to

50. standardize the treatment process using clinical guidelines and critical pathways in accordance to best practices to ensure that patients receive the best and most effective treatment.
The Government of Malaysia has decided to introduce a national health care financing system to support the increasing health care cost and to enhance equity, accessibility, quality and efficiency in the health system. One of the element in financing is the health care provider payment mechanism based on this case-mix system. Therefore, HUKM has taken the initiative to lead the way in using case-mix system in this country and hope to extend its experience to other hospitals and insinuate its implementation to strengthen the health service in the country.

51. What Case Mix Is
Refers to the Mix of Cases of a Hospital, the Range and Type of Patients Treated
Case Mix Information can tell us How Much Money Hospitals Need According to the Patients they Actually Treat
Case Mix is Hospital Final Output, Classified into Predetermined Categories (DRGs)
Case Mix Information about Resource Use and Quality can be Used as Standards for Hospitals to Compare Based on patient characteristics
Case Mix is a Tool - Case Mix Information Provides the Knowledge to Critically Examine Patient Care and Manage Appropriately Comparative data
Emulate تقليد

52. What Case Mix Is Not A Method for Cutting Health Budgets - Case Mix
can Help Ensure that Available Funds are
Distributed Rationally •
A Tool to Control Doctors - Case Mix can be used
to Compare the Kind of Treatment Doctors Give
Patients
A Method of Changing Hospital Work Practices -
Hospitals can use Information to Examine
Practices and Identify Where Changes Might be
Needed
A way of Removing Management of Health from
Doctors and Nurses - Case Mix Enables Doctors
and Nurses to Better Manage Health Care

53. CaseMix Analysis The Ministry compares The Regions The Hospitals
The Departments
the Physicians...
...the Patients

54. NordDRG
The Nordic Medico-Statistical Committee (NOMESCO) of the Nordic Council of Ministers charged in 1995 the WHO Collaborating Centre for the Classification of Diseases in the Nordic countries with the task of designing a DRG system, possible to use after the introduction of ICD-10 and NCSP.

55. NordDRG
The objective of the design project was to create a patient classification system that is public domain, with openly accessible grouping definitions, based on the ICD-10 and NCSP, and easily maintainable and possible to develop beyond DRGs, in order to meet the requirements of Nordic clinical practice.
The project was divided into three phases

56. 1). Conversion tables between ICD-10 and ICD-9-CM and NSCP and ICD-9-CSP(classification of surgical procedures) , respectively, were produced and published
Secondly, standardised HCFA-like DRG Definitions were created, directly using ICD-10 and NCSP codes
Thirdly, grouping software was designed both as a “Common Nordic” version and as national versions, containing national modifications of the ICD-10 and NCSP
The NordDRG Definitions and the NordDRG Grouper (national versions) are the property of the national health authorities. They are responsible for the national versions and their distribution within their respective country

57. NordDRG
The Nordic Medico-Statistical Committee (NOMESCO) of the Nordic Council of Ministers initiated in 1994 a project to create a Nordic case-mix system to make it possible to compare health care statistics in the Nordic countries. The case-mix system was also aimed for planning, budgeting, management and financing inpatient care at hospital.
The objective of the design project was to create a patient classification system that is public domain, with openly accessible grouping definitions, based on the ICD-10 and NCSP (Nomesco Classification of Surgical Procedures). The system has to be easily maintainable and possible to develop beyond DRGs, in order to meet the requirements of Nordic clinical practice. The system also had to derive from the logic in HCFA-DRG version 12.0.
In 1996 the first version of NordDRG was developed. From 1997 the new system was in practice in Stockholm County Council in Sweden and in some health care districts in Finland. In 2002 all Nordic countries use NordDRG except Island

58. Current condition
Around 20 hospitals in Sweden have case-costing systems for inpatient care in use (or 25% of the yearly cases in Sweden). The Federation of Swedish County Councils collects case-costing data from the hospitals to a national case-costing database.
The National case-costing project has been running since The project was ending in year Case-costing will continue as a part of the ordinary activity at the Federation of Swedish County Councils. Approximately 50% of the County Councils have local case-costing projects. This will hopefully lead to more cases in the case-costing database in the near future; many new hospitals are already implementing case-costing systems. Case-costing systems are today non-compulsory in Sweden.
Case-costing systems for psychiatry, outpatient care and primary care are also on the list for development. A few Swedish hospitals already implemented case costing for outpatient care
non-compulsoryغير اجباري

59. 1980
The classification “Diagnosis Related Groups” (DRG) was established by Professor Robert Fetter and Jon Thompson from Yale University to categories patient scene in American hospital. The version that has been used contained 383-diagnosis group known as DRG, the first version using ICD-8 as “Grouping Principal System”. The second version contained 467 DRG group, which was created in line with ICD-9 and ICD-9-Cm for operation procedures.
1983
Health Care Financing Authority (HCFA) in USA used case-mix system to support the health services under social scheme insurance that is Medicare and Medicaid.
1990
Case mix system was introduced to Australia. The research over case-mix system has been resembled by the health services authority in South Australia, New South Wales University and the Royal Children’s Hospital in Melbourne. After that the case-mix system has been broaden to all places in Australia.
1992
Case-mix system was introduced in Singapore and has been tried as payment system in health service.
1994
Case-mix system was introduced in Thailand under the Thailand National Scheme insurance.
1997
The research on case-mix system as a method of health care financing in Malaysia was approved and given the budget under the IRPA Top-Down project to UKM, UM, USM and Ministry Of Health Malaysia.
Schemeطرح
Authorityمنبع موثق

65. TYPE OF CASE-MIX SYSTEM
From the first version of DRG in 1983, some researcher have modified the DRG for their used with changes made to satisfy the disease pattern in their country.
All Patient Refined DRGS (APR-DRGS) are using the patient sickness to ensure that the classification can only detected the patient that really needed the more resources causes by the chronic disease. Australia used their own Case-mix system that is Australia National DRGS (AN- DRG) since United Kingdom used Health Care Resources Group (HRG), and Canada used Classification Case-mix Group (CGM).
UKM hospital will be using the latest Case-mix system that is IR-DRG (International Refined DRG) that contains 965 groups .This system is fundamental to ICD-10 for main diagnosis and ICD-9CM for operation procedure. This IR-DRG classification will be a principle to achieve the establishment of Malaysia own Case-mix system in the future. The classification contains all group age and almost all-major operation that has been done in one hospital.
Catenationترتيب

66. NordDRG weight list
The DRG-weight is a relative measure of care and treatment costs for an average patient in a DRG. A high weight indicates high cost. To get weight lists that are validated and representative the calculation must be based on a large database. The average cost for all cases in the database have the state of DRG-weight 1.0. The weight for each DRG is calculated by dividing the average cost for each DRG with cost that represents DRG-weight 1.0.
The DRG average cost is the basis for cost comparability in the calculation of cost-weights. Patients with a long length of stay or high cost may have a disproportional influence on the average cost. The method to exclude those cases from the database is called trimming and the excluded cases are representative
Disproportional بي تناسب

67. NordDRG weight list
called outliers. About five percent of the database are technical defined as outliers. Trimming the data is to improve the comparability of the data. When weight lists are used in a reimbursement system the outliers get paid separate. Limits for outliers are specified in the weight list.
Annually CPK produce a national weight lists based on the national case-costing database. All hospitals in the case-costing database have calculated the cost by the cost per case method.
The national weight lists are mainly used as a reference list. There is a predominance of region hospitals in the national case-costing database why the cost weights are not absolutely

68. Australia
AN-DRG( Australian National DRG) اولين سيستم طبقه بندي DRG استراليا كه توسط 3M و common wealth بصورت مشترك ايجاد شد . بين 1992 و 1996 نسخه هاي 1.0, 2.0, 2.1, 3.0 and 3.1 ايجاد شده است
AR-DRG دومين سيستم طبقه بندي DRG استراليا كه از سال 1997 ايجاد شده ونسخه هاي 3.2 ، 4.0 در سالهاي بر اساس كدهاي ICD-9-CM، 4.1 در سالهاي بر اساس اولين ويرايش ICD-10-AM ، 4.2 از سال 2001 بر اساس دومين ويرايش ICD-10-AM ، تاكنون استفاده شده اند. ساعات بيهوشي، تنفس مصنوعي و وضعيت بهداشت رواني از جمله مواردي است كه در اين سيستم در نظر گرفته شده اند. نسخه 4.2 از 23 MDC به همراه 8 pre-MDC و 7 error DRGs تشكيل شده است. MDC ها بر اساس يك سيستم بدني واحد يا اتيولوژي كه به يك تخصص پزشكي خاص مربوط مي شود، ايجاد شده اند.
MBS: Australian Commonwealth Medical Benefit Schedule در پرداخت پزشكان استراليا استفاده مي شود.

69. Australia متغيرهاي مورد استفاده براي گروه بندي AR-DRG عبارتند از:
تشخيص ها (اصلي، ساير)
اقدامات
جنس سن
نوع پايان وقايع[1]
مدت اقامت
روزهاي ترك بيمارستان (ترخيص موقت)
وزن هنگام پذيرش(براي كودكان زير يكسال)
وضعيت بهداشت رواني
ساعات تهويه مكانيكي[2]
وضعيت هايي كه بيمار در يك روز پذيرش و در همان روز ترخيص مي شود.
[1] Events end type
[2] Hours of mechanical ventilation

70. AR-DRG V4.2:

71. Germany G-DRG - Diagnosis Related Groups ICD-10 and OPS-301 Germany
The recent German Health Reform or “Gesundheitsreform 2000” will introduce a German Diagnosis Related Group (G-DRG) system in the hospital sector planned to be fully operational by Up to then run the adaptation time of the German health system on DRG-System. This reform will change the current hospital financing system on the basics of Australian DRG-System. The Departments for Psychiatry are excluded from DRG-financing.  Hospitals are using ICD-10 Version 2.0 for Diagnosis-Coding and OPS-301 for Procedure-Coding ( )

72. canada
در كانادا گروه هاي كيس ميكس (CMG) بر اساس معتبر ترين تشخيص، كه در زمان ترخيص بيشترين طول اقامت را به خود اختصاص مي دهد، ايجاد شده اند. گروه هاي كيس ميكس، مرتبا بر اساس نياز كاربران، روزآمد مي شوند. مثلا پيچيدگي بيماري و سن بيمار اخيرا در گروهها لحاظ شده است. سن بيمار از اين جهت مهم است كه بيماران كم سن و سال و افراد پير و مسن اغلب به تدابير درماني بيشتري نياز دارند.

73. America(case mix classifications)
Yale refinement DRGs
:بر اساس مطالعة پيامد هاي بيماري هاي همزمان و عوارض بهره وري از منابع بيمارستاني تنظيم شده است. همچنين تشخيص هاي ثانويه مرتبط با برخي تشخيص هاي اصلي مورد توجه قرار گرفته اند.
New York DRGs
يكپارچه سازي فعاليت هايي كه توسط مديكير انتخاب نمي شوند، ولي براي سايربيماران انجام مي شوند اين فعاليت ها براي افراد مسن انجام نمي شوند. مثل ايدز، جراحت ها، بيماري هاي نوزادان ، اعتياد دارويي و...
New York CSI DRGs
 DRGs  نمايه شدت نيويورك: توسط پژوهشگران موسسة پزشكي جانز هاپكينز در اوايل دهة 1980 ايجاد شد و به شدت بيماري در DRG توجه شد.هر تشخيص اصلي يا ثانويه براساس 4 معيار شدت بندي شد: سبك، متوسط، شديد، تهديد كنندة زندگي و زير گرو ه هايي براي هر يك در نظر گرفته شد.

74. America(case mix classifications)
Pediatric Modified DRGs (PM-DRGs)
طي سالهاي توسط انجمن ملي بيمارستان هاي كودكان و موسسات مربوطه[1] (NACHRI)براي بيماران كمتر از 17 سال ايجاد شد علت اصلي ايجاد اين سيستم اين بود كه DRG اصلي ، وضعيت هاي پرهزينه و پيچيده كودكان را كه اغلب در بيمارستان هاي تخصصي درمان مي شدند به خوبي منعكس نمي كرد. بنابراين در ارائه منابع كافي براي كودكاني كه نياز به مراقبت پزشكي خاص داشتند و براي سازمان هايي كه اين مراقبت ها را ارائه مي كردند ، مشكلاتي ايجاد مي شد. به اين ترتيب به منظور رفع اين مشكلات حدود صد DRG به DRGهاي قبلي افزوده شد.در واقع اين سيستم مكمل DRG است نه بخشي از آن.

75. LTC-DRGs long-term care diagnosis- related groups
Cases are classified into LTC-DRGs for payment based on the following six data elements:
(1) Principal diagnosis.
(2) Up to eight additional diagnoses.
(3) Up to six procedures performed.
(4) Age.
(5) Sex.
(6) Discharge status of the patient

76. England
در انگلستان ، در سال 1984، اولين كنفرانس بين المللي DRG در لندن برگزار شد.در اين كنفرانس انجمن PCS/E [1]با شركت نمايندگاني از 6 كشور اروپاي غربي تشكيل شد. از آن زمان تاكنون كنفرانس سالانه در كشورهاي مختلف اروپايي و استراليا تشكيل شده است.موضوع مورد بحث كنفرانس مفاهيم جديد در عرصه كيس ميكس است و فصلنامه رايگاني نيز در اين زمينه منتشر مي كند. امروزه اين انجمن با بيش از 50 كشور مختلف از سراسر دنيا ارتباط دارد. در كنفرانس PCS/E كه در سال 1999 در ادنس [2] برگزار شد، 3M سيستم IAP-DRG[3]را معرفي كرد كه نسخه خلاصه شده آن نيز وجود دارد كه به جاي 4 سطح داراي 3 سطح CC بوده و در مجموع 1046 گروه دارد.
[1] Patient classification systems/Europe
[2] Odense
[3] International All Patient Diagnosis Related Groups

77. France DRG در دهة 1980 به كشور اورده شد.
DRG در فرانسه HGP [1]نام گرفت. با بهره گيري ازHGP، از طريق تحليل انحراف معيار ها، گام موثري در مديريت مالي برداشته شده است. اقتصاد دانان فرانسوي علاقمند بودند با استفاده از يك مرجع خارجي از وضعيت نسبي بيمارستان ها آگاه شوند. از سال 1991، راهنماي استفاده از HGP در زمينة پزشكي سازي سيستم اطلاعاتي (MIS)[2] ايجاد شد. هدف رسيدن به يك پرداخت آينده نگر نبود، بلكه پايش و تلفيق اختصاص يك بودجة سراسري به بيمارستان هاي عمومي بود. پس از مذاكره ميان وزارت بهداشت و وزارت بودجة فرانسه، ميزان عمومي برآمد هاي خاص در سطح ملي مشخص شد. در سطح محلي، بودجة ساليانه برابر است با بودجة قبلي ضربدر ميزان تورم. در اين اقدام مالي، ضرر و زيان ها و نوسانات احتمالي به علت سرمايه گذاري هاي محلي و همچنين افزايش يا كاهش فعاليت بيمارستان ناديده گرفته مي شود
در مقايسه با DRG، شمارة گروه ها تغيير كرده است. برخي گروه ها اضافه شدند، درحاليكه برخي از سيستم خارج شدند، همچنين تعدادي از تشخيص ها از يك ردة اصلي به ردة ديگر منتقل شده اند.
[1] Homogeneous groups of patients
[2]Medicalisation of the Information System

78. Other countries Thailand Taiwan Indonesia Denmark Finland Italy
Malaysia
Singapore

79. ايران
در ايران اين نوع روش پرداخت بکار گرفته مي شود و نظام طبقه بندي اي که به عنوان پايه و اساس جهت بکارگيري روش پرداخت موردي استفاده مي شود نظامي با عنوان نظام" گلوبال" است. در اين نظام، بيماران بر طبق 60 مورد از اعمال جراحي شايع طبقه بندي مي گردند. نظام" گلوبال" در مقايسه با نظام "گروه هاي مرتبط تشخيصي" داراي نواقص بسياري است. نظام" گلوبال"، موارد بيماري را شامل نشده و تنها در مورد اعمال جراحي و تنها در 60 مورد کاربرد دارد. طبقات تشخيصي اصلي، گروه های مرتبط تشخيصی پايه که در نظام هاي "گروه هاي مرتبط تشخيصي" بطور جامع و کامل در نظر گرفته شده است در نظام " گلوبال" وجود ندارد. همچنين طبقاتي جهت اطلاعات غيرمعتبر و متناقض، و وضعيت ترخيص بيمار در نظر گرفته نشده است. متغيرهاي سن، جنس، وجود يا عدم وجود عوارض و بيماري هاي همراه، سطح خاص عوارض و بيماري هاي همراه، وزن زمان تولد/

80. ايران
پذيرش در نوزادان وجود نداشته و شدت بيماري و يا سطح پيچيدگي کلينيکي بيمار، و نيز خطرمرگ را نمي توان با توجه به اين نظام تعيين نمود . در نظام هاي "گروه هاي مرتبط تشخيصي" به هر"گروه"، کدي تعلق مي گيرد که با کدهاي طبقه بندي بين المللي بيماري ها مرتبط و هماهنگ است، اما در نظام " گلوبال" کدگذاري انجام نمي شود. از طرفي ديگر عامل وزن نسبي يا وزن هزينه اي، که در محاسبه هزينه بيمار با توجه به نظام "گروه های مرتبط تشخيصي" جهت هر گروه، به طور جداگانه تعيين مي شود در نظام " گلوبال" درنظر گرفته نشده است. بدين ترتيب مي توان اظهار داشت نظام " گلوبال" در مقايسه با نظام "گروه های مرتبط تشخيصي" داراي کمبود ها و نواقصي است .