I-Medicare kunye neenkampani ze-inshorensi zempilo ezininzi zihlawula izibhedlele zisebenzisa ii-DRG, okanye iinqununu ezinxulumene nokuxilongwa . Oku kuthetha ukuba isibhedlele ihlawulwa ngokusekelwe kwisigulana esagunyazisiweyo kunokuba isekelwe kwinto esetyenziselwe ukunyamekela isigulane esibhedlele.
Ukuba isibhedlele singaphatha isigulane ngelixa sichitha imali encinci kuneNtlawulo ye-DRG yesi sigulo, isibhedlele yenza inzuzo.
Ukuba, ngelixa unyanga isigulane esibhedlele, isibhedlele sisebenzisa imali engaphezulu kweNtlawulo ye-DRG, isibhedlele siya kulahlekelwa yimali kwisigulane eso. Oku kuthetha ukulawulwa kweendleko zonyango ngokukhuthaza ukunyamekela kakuhle kwezigulane ezibhedlele.
Isizathu Sokuba Ufanele Unakekele Njani i-DRG echongiweyo
Ukuba unesigulane, ukuqonda izinto ezisisiseko zeziphi iziganeko ezichaphazela isabelo sakho se-DRG kunokukunceda ukuba uqonde kangcono ibhilidi yakho yesibhedlele, yintoni inkampani yakho yomshuwalense okanye i-Medicare ehlawulayo, okanye kutheni ubelwe i-DRG ethile.
Ukuba unogqirha kunokuba isigulane, ukuqonda inkqubo yokunikezela i-DRG kunokukunceda uqonde ukuba amaxwebhu akho kwirekhodi yezokwelapha ichaphazela njani i-DRG kunye nantoni na i-Medicare iya kubuyiselwa esibhedlele. Kuya kukukunceda uqonde ukuba kutheni amakhowudi kunye nabasebenzi bokuthobela bebuza imibuzo abayicelayo.
Amanyathelo okunquma i-DRG
Oku kuhamba ngokulula kwamanyathelo okubaluleka okusetyenziswa kwe-coder esibhedlele ukucacisa i-DRG yesigulane esibhedlele. Oku akukona nje indlela umgcini-coder enza ngayo; kwihlabathi lenene, amakhowudi anesininzi uncedo kwi software.
- Qinisekisa i-diagnostic yesiqununu sokungeniswa kwesigulane.
- Qinisekisa ukuba ingaba yinkqubo yophenyo okanye akukho.
- Qinisekisa ukuba kukho naziphi na iziganeko ezinzima okanye iingxaki. Iimeko ezinomsocoko yinkinga yonyango eyongezelelweyo eyenzeka ngexesha elifanayo njengengxaki yonyango eyintloko. Kungenzeka kube yinkinga ehambelanayo, okanye ayihambelani ngokupheleleyo.
Umzekelo
Masithi umdala uMnuz Gomez uya esibhedlele enentanyeni yentsimbi ephukileyo, eyaziwa ngokuqhelekileyo njengento ephukile . Udinga ukuhlinzwa kwaye uphumelele ukutshintshwa kwe-hip . Ngethuba uhlaziya kwi-hip operation, ingxaki yakhe engapheliyo yintliziyo iyaphupha kwaye ikhula ngokunyaniseka kwentliziyo ye -systolic congestive heart failure . Ekugqibeleni, oogqirha bakhe bafumana uMnu. Gomez intliziyo engaphumeleli phantsi kokulawula, uyaphilisa kakuhle, kwaye ukhululwa kwisibonelelo sokuhlala esibhedlele sonyango ukuze abuyele ekhaya.
Ukuxilongwa kwinqununu kaNksz Gomez kuyakuba yintambo yentamo yesifazane. Inkqubo yakhe yokugqirha inxulumene nokuxilongwa kwakhe kwinqununu kwaye yindawo yokutshintshwa kwayo yonke indawo. Ukongezelela, unesimo esibi kakhulu: i-sytolic acestive heart failure.
Xa umgcini-coder uyifake yonke le ngcaciso kwisofthiwe, isofthiwe iya kukhupha i-DRG ye-469, enesihloko esithi "Ukutshintshwa okuManyeneyo okanye ukuxhaswa koBuchule obuphantsi kweMCC."
Okunye malunga neSinyathelo 1: iNgcaciso yeNtloko
Inxalenye ebaluleke kakhulu yokunikezela i-DRG ifumana uvavanyo oluchanekileyo lwenqununu. Oku kubonakala kulula kodwa kunokuba nzima, ngakumbi xa isiguli sinenkinga ehlukeneyo yezokwelapha eqhubekayo ngexesha elifanayo. Ngokutsho kweCMS , "I-diagnostic inqununu yimeko esekelwe emva kokufundiswa ukuba ibe yinkxalabo yokumkelwa."
I-diagnostic inqununu kufuneka ibe yingxaki ekhoyo xa uvalelwa esibhedlele; ayikwazi ukuba yinto ephuhlisiwe emva kokungena kwakho. Oku kunokuba bukhohlisayo kuba ngezinye amaxesha ugqirha wakho akakwazi ukuba yintoni ephosakeleyo nawe xa uvalelwa esibhedlele.
Umzekelo, mhlawumbi ungeniswa esibhedlele ngeentlungu zesisu, kodwa ugqirha akazi nto ebangela intlungu. Kuthatha ixesha elithile ukufumanisa ukuba unomdlavuza wekolon kwaye loo mdlavuza wekoloni yimbangela yentlungu yakho. Ekubeni umhlaza wekolon ukhona ekungenisweni, nangona ugqirha engazange azi ukuba yintoni ebangela intlungu xa uvumelekile, umhlaza wekolon unokwabelwa njengesifo esiyintloko.
Okunye malunga neSinyathelo 2: Inkqubo yokuPhepha
Nangona oku kubonakala kunqunywe kwaye kuyomile, njengezinto ezininzi ze-inshurensi yempilo kunye ne-Medicare, akunjalo. Kukho imigaqo emibini eqinisekisa ukuba inkqubo yonyango ifuthe njani i-DRG.
Okokuqala, i-Medicare ichaza ukuba yiyiphi into ebalulekileyo njengenkqubo yokucoca ngenjongo yokunikezela i-DRG, kwaye yintoni engabonakali njengenkqubo yokucoca. Ezinye izinto ezinjengeendlela zokugulisa isigulane esinemigaqo ayibonakali njengenkqubo yokucwangcisa xa unikela i-DRG yakho.
Okwesibini, kubalulekile ukwazi ukuba inkqubo yokucubungula ngokubhekisele kumbuzo inqanaba elifanayo lokuxilonga njengenqununu yokuxilongwa. Zonke iziphumo zokuxilonga ziyinxalenye yoluhlu olukhulu lokuxilonga, olusekelwe kwiinkqubo zomzimba. Ukuba i-Medicare ibona inkqubo yakho yokugqirha ukuba ibe kwisigaba esifanayo sokuxilonga njengoluhlu oluphambili lwe-diagnostic, i-DRG yakho iya kuba yinto ehlukileyo kunokuba i-Medicare ibona ukuba inkqubo yakho yokugqirha ingahambelani ne-diagnostic yakho. Kulo mzekelo ukhankanywe ngasentla kunye noNksz Gomez, u-Medicare uthatha utyando lokutshintshwa kwendawo yokuqhaqhaza kunye ne-hip ephukile ukuba ibe kwisigaba esifanayo sokuxilonga.
Okungakumbi malunga neSinyathelo se-3: Iimeko kunye neengxaki ezixhasayo
Ekubeni isebenzisa ezinye izibonelelo kwaye mhlawumbi iindleko zokunyamekela isigulane esifana noNksz Gomez onesiqheko esiphukileyo kunye nesifo esingenakunzima sokuphelelwa yintliziyo kunokunyamekela isigulane esinomphunga ophukileyo kunye nezinye iingxaki, i-DRG ezininzi zithatha oku ingqalelo. I-Medicare ize idibanise phakathi kweemeko ezinzima ezifana ne-heart failure ye-heart failure okanye i-sepsis, kunye neemeko ezinzima kakhulu ezifana ne-COPD engapheliyo ngenxa yeemeko ezinkulu ezidinga ukuba zifumane ezinye izixhobo zokuphatha ngaphandle kweemeko ezinzima kakhulu. . Kwiimeko ezifana nale, kukho i-DRG emithathu eyahlukileyo, eyaziwa njenge-tripg ye-DRG:
- I-DRG ehlawuleyo ephantsi yokuxilongwa kwinqununu ngaphandle kweemeko ezixhamla okanye iingxaki.
- I-DRG ehlawulwa ngokukhawuleza yokuxilongwa kwinqununu kunye nesimo esingenakunzima kakhulu. Oku kwaziwa ngokuba yi-DRG eneCC okanye i-omorbid c .
- I-DRG ehlawulekayo ephezulu yokuxilongwa kwinqununu kunye neemeko ezinkulu ze-comorbid, ezaziwa ngokuba yi-DRG nge-MCC okanye i-ajor c omorbid c ondition.
Ukuba unogqirha ucela imibuzo kwi-coder okanye kwisebe lokuthobela, le mibuzo iza kugxininiswa ekugqibeleni ukuba isigulane siphathwe kwiCC okanye i-MCC ngexesha lakhe esibhedlele lihlala ngaphezu kokuphathwa kwinqununu ukuxilongwa.
Ukuba unesigxina esibhekisele i-bill yakho okanye inkcazo yeenzuzo kunye nenkampani yakho yonyhorensi yempilo ihlawula izibhedlele ngokusekelwe kwinkqubo yokuhlawula i-DRG, uya kubona oku kuboniswe kwisihloko se-DRG owabelwe yona. Isihloko se-DRG esibandakanya "nge-MCC" okanye "neCC" kuthetha ukuba, ngaphezu kokunyanga i-diagnostic inqununu ukuba uyangeniswa, isibhedlele nayo isetyenzisile imithombo yayo yokunyanga imeko ye-comorbid ngexesha lokulala esibhedlele.