I-Medicare nezinkampani eziningi zomshuwalense wezempilo zikhokhela izibhedlela zisebenzisa i-DRG, noma amaqembu ahlobene nokuxilongwa . Lokhu kusho ukuthi isibhedlela siyakhokhwa ngokususelwa ekuxilongweni kwesiguli esivunyelwe kunokuba sisekelwe ekusebenziseni ngempela ukunakekelwa kwesiguli esibhedlela.
Uma isibhedlela singaphatha isiguli ngenkathi sisebenzisa imali encane kunokukhokha kwe-DRG yalesi sifo, isibhedlela senza inzuzo.
Uma, ngenkathi ukwelapha isiguli esibhedlela, isibhedlela sisebenzisa imali engaphezu kokukhokha kwe-DRG, isibhedlela sizolahlekelwa imali kulesi siguli esibhedlela. Lokhu kusho ukulawula izindleko zokunakekelwa kwezempilo ngokukhuthaza ukunakekelwa okuphumelelayo kweziguli ezibhedlela.
Okwenza Ufanele Uzinakekele Kanjani I-DRG Inqunywa
Uma unesiguli, ukuqonda okuyisisekelo ukuthi yiziphi izinto ezithinta isabelo sakho se-DRG singakusiza ukuthi uqonde kangcono isikweletu sakho esibhedlela, ukuthi iyiphi inkampani yakho yomshuwalense wezempilo noma uMederal ukukhokhela, noma kungani unikezwe i-DRG ethile.
Uma ungudokotela kunesiguli, ukuqonda inqubo yokwahlulela i-DRG kungakusiza uqonde ukuthi amadokhumenti akho kurekhodi yezokwelapha ahlasela kanjani i-DRG nokuthi yiyiphi imithi ezobuyisela esibhedlela esinikezwe isiguli. Kuzokusiza futhi uqonde ukuthi kungani amakhodi kanye nabasebenzi bokuthobela ukubuza imibuzo abayicelayo.
Izinyathelo Zokunquma i-DRG
Lokhu kuyinkimbinkimbi elula yokwenza izinyathelo eziyisisekelo isikhombimsebenzisi esibhedlela esisebenzisayo ukucacisa i-DRG yesiguli esibhedlela. Lokhu akukona ngqo ukuthi i-coder yenza kanjani; ezweni langempela, amakhodi anezinsiza eziningi ezivela kwisofthiwe.
- Hlola ukuxilongwa okuyinhloko kokungenwa kwesiguli.
- Ukunquma ukuthi ngabe kunenqubo yokuhlinzeka noma cha.
- Qinisekisa ukuthi ngabe kukhona yini izimo ezibucayi ze-comorbid noma izinkinga. Isimo se-comorbid yinkinga yokwelashwa eyengeziwe eyenzeka ngesikhathi esisodwa njengenkinga yezokwelapha eziyinhloko. Kungenzeka kube inkinga ehlobene, noma ayihambisani ngokuphelele.
Isibonelo
Ake sithi uNkk. Bieber osekhulile uya esibhedlela ngensipho ephukile yowesifazane, eyaziwa ngokujwayelekile njenge- hip ephukile . Udinga ukuhlinzeka futhi abuyele endaweni ephelele ye-hip . Ngenkathi eselamekile ekuhlinzekeni kwakhe kwe-hip, inkinga yakhe yenhliziyo engapheli ivuleka futhi iqala ukuhluleka kwenhliziyo ekhululekile ye- systolic. Ekugcineni, odokotela bakhe bathola ukuhluleka kwenhliziyo kaMnuz Gomez Gomez, uphulukisa kahle, futhi uhanjiswe esibhedlela sokuhlala esibhedlela sokugula esibhedlela ngaphambi kokuba abuyele ekhaya.
Ukuxilongwa okuyinhloko kaNksz Gomez kungaba ukwephulwa kwentamo yesifazane. Inqubo yakhe yokuhlinzekwa ihlobene nokuxilongwa kwakhe okuyinhloko futhi ishintsho esiphezulu se-hip. Ukwengeza, unesimiso esikhulu se-comorbid: i-sytolic acestive heart failure.
Uma i-coder ixhuma yonke le lwazi kwisofthiwe, isofthiwe izokhipha i-DRG ye-469, enesihloko esithi "Okuyinhloko Yokushintshaniswa Okuxhunyanisiwe noma Ukunamathiswa Okuphansi Kwe-MCC."
Okuningi mayelana nesinyathelo 1: Ukutholwa Okuyinhloko
Ingxenye ebaluleke kunazo zonke yokwahlulela i-DRG ukuthola ukuthola ukuhlolwa okuyinhloko okulungile. Lokhu kubonakala kulula kodwa kungaba nzima, ikakhulu uma isiguli sinenkinga yezokwelapha eziningana eziqhubekayo ngesikhathi esisodwa. Ngokusho kwe-CMS , "Ukuxilongwa okuyinhloko yisimiso esisungulwe ngemuva kokutadisha ukuthi sibe ngokuyinhloko ekutholeni ukuvuma."
Ukuxilongwa okuyinhloko kufanele kube yinkinga eyayikhona lapho usungeniswa esibhedlela; ngeke kube yinto eyakhiwe ngemva kokungena kwakho. Lokhu kungaba yinto ekhohlisayo kusukela ngezinye izikhathi udokotela wakho akakwazi ukuthi yini ngempela engalungile nawe uma usungeniswa esibhedlela.
Ngokwesibonelo, mhlawumbe ungeniswa esibhedlela ngezihlungu zesisu, kodwa udokotela akazi ukuthi yini ebangela ubuhlungu. Kuthatha isikhathi esincane ukuthola ukuthi unomdlavuza wekoloni nokuthi umdlavuza wekolon uyimbangela yobuhlungu bakho. Njengoba umdlavuza wekoloni wawukhona ekungenisweni, nakuba udokotela engazi ukuthi yini eyabangela ubuhlungu lapho uvunyelwa, umdlavuza wekoloni ungabelwa njengesifo sakho sokutholwa.
Okuningi mayelana nesinyathelo 2: Inqubo Yokuhlinzeka
Nakuba lokhu kubonakala kunqunywe futhi kuyomile, njengezinto eziningi mayelana nomshuwalense wezempilo kanye ne-Medicare, akunjalo. Kunemithetho eminingana enquma ukuthi inqubo yokuhlinzwa ingathinta kanjani i-DRG nokuthi kanjani.
Okokuqala, i-Medicare ichaza ukuthi yikuphi okubaluleka njengenqubo yokuhlinzekela ngezinhloso zokwahlulela i-DRG, futhi yini engabonakali njengendlela yokuhlinzwa. Ezinye izinto ezibonakala njengezinqubo zokuhlinzekela isiguli enenqubo akuzona njengenqubo yokuhlinzeka lapho ubeka i-DRG yakho.
Okwesibili, kubalulekile ukwazi ukuthi inqubo yokuhlinzekwa embukisweni isesigaba esifanayo sokuxilonga njenge-diagnostic oyinhloko. Zonke izifo zokuxilonga eziyinhloko ziyingxenye yesigaba esikhulu sokuxilonga, esisekelwe esimweni sezinhlelo zomzimba. Uma i-Medicare ibheka ukuthi inqubo yakho yokuhlinzwa ibe isigaba esifanayo sokuxilonga esiyinhloko njengesifo sakho esiyinhloko sokuxilongwa, i-DRG yakho iyohluka uma ngabe i-Medicare ibheka ukuthi inqubo yakho yokuhlinzwa ayihambisani nokuxilongwa kwakho okuyinhloko. Kulesi sibonelo esingenhla noNksz Gomez, u-Medicare ubheka ukuhlinzwa okuqashisayo kwe-hip kanye ne-hip ephukile ukuba ibe kwisigaba esifanayo sokuhlonza.
Okuningi mayelana nesinyathelo sesi-3: Izimo ze-Comorbid nezinkinga
Njengoba isebenzisa izinsiza eziningi futhi kungenzeka ukuthi izindleko ezingaphezu kokunakekela isiguli esifana noNksz Gomez onokuhlukumezeka kwenhliziyo ephukile kunokuba ayenakekele ukunakekela isiguli esiphukile futhi asikho nezinye izinkinga, ama-DRG amaningi athatha lokhu ukucabanga. I-Medicare ibuye ihlukanise phakathi kwezimo ezinkulu ze-comorbid ezifana nokuhluleka kwe-heart congestive ukuhluleka noma i-sepsis, kanye nezimo ezingekho-ezinkulu kakhulu njenge-flare-up of COPD engapheli ngoba izimo ezinkulu ze-comorbid zidinga izinsiza eziningi zokwelapha kunezimo ezingavamile kakhulu ze-comorbid . Ezimweni ezinjengalezi, kungase kube khona ama-DRG amathathu ahlukene, awaziwa ngokuthi i-tripg triplet:
- I-DRG ekhokhelwayo ephansi yokuxilongwa okuyinhloko ngaphandle kwezimo ze-comorbid noma izinkinga.
- I-DRG ekhokhelwayo ephakathi ukuze ixilongwe ngokuyinhloko nge-non-so-major-comorbid condition. Lokhu kwaziwa ngokuthi i-DRG nge-CC noma i-omorbid c ondition.
- I-DRG ekhokhelwayo ephakeme ukuxilongwa okuyinhloko ngesimo esikhulu se-comorbid, esaziwa ngokuthi i-DRG nge-MCC noma i-ajor c omorbid c ondition.
Uma ungudokotela uthola imibuzo evela kumcoder noma umnyango wokuthobela, eziningi zale mibuzo zizohloswe ekunqumeni ukuthi isiguli siphathwe i-CC noma i-MCC ngesikhathi esibhedlela sakhe sihlala ngaphezu kokuphathwa kwesikhulu ukuxilongwa.
Uma ngabe isiguli sibheka umthethosivivinywa sakho noma incazelo yezinzuzo futhi inkampani yakho yomshuwalense wezempilo ukhokhela izibhedlela ngokusekelwe ohlelweni lokukhokha lwe-DRG, uzobona lokhu kuboniswe isihloko se-DRG owabelwe yona. Isihloko se-DRG esihlanganisa "nge-MCC" noma "ne-CC" sisho ukuthi, ngaphezu kokuphatha ukuxilongwa okuyinhloko owavunyelwe, isibhedlela sasebenzisa nemithombo yaso yokwelapha isimo se-comorbid ngesikhathi sakho esibhedlela.