(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon
Implementation of ICD-10, Implementation: ICD-10: Upon Implementation of ICD-
10, ASC X12: September, 23 2014)
The A/B MAC (A) pays for inpatient hospital services on the basis of a rate per discharge
that varies according to the MS-DRG to which a beneficiary's stay is assigned. Each MSDRG
represents the average resources required to care for a case in that particular MSDRG
relative to the national average of resources consumed per case. The MS-DRG
weights used to calculate payment are in the Pricer DRGX file.
The A/B MAC (A) uses the GROUPER program to assign the MS-DRG number.
GROUPER determines the MS-DRG from data elements reported by the hospital. This applies to all inpatient discharge/transfer bills received from both PPS and non-PPS
facilities, including those from waiver States, long-term care hospitals, and excluded units.
T
he Pricer (PPSMAIN) driver program calls the correct fiscal year GROUPER based
upon the discharge date. If the A/B MAC (A) or shared system writes its own driver
program, it must access the GROUPER for the correct FY based on discharge date.
GROUPER does not determine the MS-DRG price. GROUPER input/output are specified
below. The A/B MAC (A) determines the best place in its total system to place the
GROUPER program.
Grouper requires the following items:
1. Principal and up to 24 other diagnoses
2. Principal and up to 24 additional procedures
3. Age at last birthday at admission
4. Sex (1=male and 2=female)
5. Discharge destination (patient status code from the claim)
The claim sex coding is M for male and F for female while GROUPER is l for male and 2
for female. Discharge destination codes are similar to claim definitions for patient status
except codes 20-29 are summarized as 20. The A/B MAC (A) calculates age at
admission. GROUPER needs age rather than date of birth.
Grouper responds with the following information:
1. Major diagnostic category
2. MS-DRG number
3. Grouper return code (a one position code indicating the action taken by the
program)
4. Procedure code used in determining the MS-DRG
5. Diagnosis code used in determining the MS-DRG
6. Secondary diagnosis code used in determining the MS-DRG, if applicable
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