Review of the ar-drg classification Case Complexity Process



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Review of the AR-DRG Classification Case Complexity Process: Final Report


1 August 2014

Prepared for the Independent Hospital Pricing Authority



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Contents

Review of the AR-DRG Classification Case Complexity Process: Final Report 1

Glossary of Abbreviations 4

Executive Summary 8

Overview 9

Aims of the Review of the Case Complexity Process 10

1Review the current Patient Clinical Complexity (PCCL) process and identify improvements and modifications. 10

2Determine the codes considered significant (currently the Complication and Comorbidity (CC) codes) in measuring case complexity. 10

3Determine whether there is a need for separate CC codes and/or matrix for paediatric and geriatric age splits. 10

4Determine whether more levels of complexity for significant diagnoses are required (currently for medical DRGs there are three Complication and Comorbidity Level (CCL) values and for surgical DRGs there are four CCL values). 10

5Examine whether more levels of complexity for the overall episode PCCL score are required (currently there is a maximum value of four). 10

6Determine whether the condition onset flag (COF) data should impact the case complexity score when the COF value indicates that the condition arose during the current episode of care. 10

7Validate codes that are to be significant to the DRG classification and the clinical reasonableness of the final case complexity results through clinical consultation. 10

Important terminology 11

Methodology 12

Key Findings and Recommendations 13

Implications 16

Stability of the Episode Clinical Complexity Model 17

Episode Clinical Complexity Model implementation 18

Changes to episode grouping 19

Private Hospitals 20

Education about the Episode Clinical Complexity Model and its implications 21

Next steps 22

8Introduction 23

9Determine the codes considered significant (currently the Complication and Comorbidity (CC) codes) in measuring case complexity. 25

10Determine whether there is a need for separate CC codes and/or matrix for paediatric and geriatric age splits. 25

11Determine whether more levels of complexity for significant diagnoses are required (currently for medical DRGs there are three Complication and Comorbidity Level (CCL) values and for surgical DRGs there are four CCL values). 25

12Examine whether more levels of complexity for the overall episode PCCL score are required (currently there is a maximum value of four). 25

13Determine whether the condition onset flag (COF) data should impact the case complexity score when the COF value indicates that the condition arose during the current episode of care. 25

14Validate codes that are to be significant to the DRG classification and the clinical reasonableness of the final case complexity results through clinical consultation. 25

14.1Background 26

14.2Brief history and development of DRGs in Australia 27

14.3Use of costing data in DRG Refinement 28

14.4Current case complexity definitions 30

14.5Case complexity processing within the current AR-DRG classification 31

14.6Approaches to DRG development taken internationally to account for complications and comorbidities 32

14.6.1The United States 33

14.6.2Germany 34

14.6.3France 35

14.6.4Canada 36

14.6.5England 37

14.6.6Other 38

14.6.7In summary 39

14.7Episode Clinical Complexity Model terminology 40

14.8Governance and consultation process 41

14.9Project Overview 44

15Data preparation 45

15.1Source data 46

15.2ICD-10-AM mapping 47

15.3Data exclusions 48

16Using Adjacent DRG and diagnosis cost profiles to evaluate AR-DRG Version 7.0 Complications and Comorbidities Levels 49

16.1ADRG cost profiles 50

16.2Diagnosis cost profiles 52

16.3Evaluation of AR-DRG V7.0 CCLs using diagnosis cost profiles 54

17The Episode Clinical Complexity Model 57

17.1Summary of the development of the Episode Clinical Complexity Model 58

17.1.1Measuring relative changes in cost associated with diagnosis cost profiles 59

17.1.2Standardising the diagnosis relative costs within each ADRG 62

17.1.3Combined diagnosis relative cost associations at the episode level 63

17.2Formal development of the Episode Clinical Complexity Model 64

17.2.1Diagnosis exclusions 65

17.2.2Modelling of ADRG costs 66

17.2.3Estimation of relative costs associated with diagnoses within the context of ADRGs 75

17.2.4Derivation of the Diagnosis Complexity Level 77

17.2.5Combining Diagnosis Complexity Levels across episodes and derivation of the Episode Clinical Complexity Score 89

17.2.6ECCS formula 91

18Treatment of the Principal diagnosis in classification design 96

18.1The DRG Classification Process 97

18.2Did the diagnoses include acute quadriplegia or paraplegia? The role of the Principal diagnosis in AR-DRG development 100

18.3Principal diagnosis impact on cost 102

19Guiding principles for Diagnosis Complexity Level assignment 107

19.1Diagnosis Complexity Level Assignment 108

19.2DCL scope guiding principle 1 109

19.2.1Group 1: Chapter 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) 110

19.2.2Group 2: Chapter 21 Factors influencing health status and contact with health services (Z00-Z99) 111

19.2.3Group 3: Unacceptable principal diagnoses 112

19.2.4Group 4: Special case exclusions 113

Codes that add descriptive information to an already assigned ICD-10-AM code 113

Sequelae (late effect) codes not appearing in Group 3. 113

Full-time dagger (aetiology) codes. 113

Conditional Exclusions (CEs) 113

19.3DCL scope guiding principle 2 115

19.3.1Codes identified as ‘in scope’ for DCL assignment from Groups 1– 3 above 116

20The use of condition onset flag in classification design 118

20.1Background 119

20.2Is there a potential role for COF in classification development? 121

20.3Other Considerations 123

20.3.1Retaining the integrity of the COF information 124

20.3.2Treating at risk patients 125

20.4In summary 126

21Evaluation of performance of the ECC Model 127

21.1Comparison of the 5-category ECCS models against the PCCL model 131

21.2Comparison of the 5-category ECCS models against the AR-DRG classification 133

21.3Comparison of performance across all models 136

21.4Comparative performance on paediatric episodes 141

21.5Comparative performance on geriatric episodes 144

22Continued refinement of ECC Model 148

22.1Ongoing evaluation and refinement of methodological and technical components of the ECC Model 149

22.1.1Enhancing DCL precision 150

22.2Ongoing evaluation and refinement of empirically derived components of the ECC Model 151

22.2.1Sample variation and DCL stability 152

23Conclusion 156

24References 159

25Appendices 162

26List of Figures 163



27List of Tables 164
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