[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR412.60]



[Page 480-481]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 412_PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES

--Table of Contents

 

Subpart D_Basic Methodology for Determining Prospective Payment Federal 

                   Rates for Inpatient Operating Costs

 

Sec. 412.60  DRG classification and weighting factors.





    (a) Diagnosis-related groups. CMS establishs a classification of 

inpatient hospital discharges by Diagnosis-Related Groups (DRGs).

    (b) DRG weighting factors. CMS assigns, for each DRG, an appropriate 

weighting factor that reflects the estimated relative cost of hospital 

resources used with respect to discharges classified within that group 

compared to discharges classified within other groups.

    (c) Assignment of discharges to DRGs. CMS establishs a methodology 

for classifying specific hospital discharges within DRGs which ensures 

that each hospital discharge is appropriately assigned to a single DRG 

based on essential data abstracted from the inpatient bill for that 

discharge.

    (1) The classification of a particular discharge is based, as 

appropriate, on the patient's age, sex, principal diagnosis (that is, 

the diagnosis established



[[Page 481]]



after study to be chiefly responsible for causing the patient's 

admission to the hospital), secondary diagnoses, procedures performed, 

and discharge status.

    (2) Each discharge is assigned to only one DRG (related, except as 

provided in paragraph (c)(3) of this section, to the patient's principal 

diagnosis) regardless of the number of conditions treated or services 

furnished during the patient's stay.

    (3) When the discharge data submitted by a hospital show a surgical 

procedure unrelated to a patient's principal diagnosis, the bill is 

returned to the hospital for validation and reverification. CMS's DRG 

classification system provides a DRG, and an appropriate weighting 

factor, for the group of cases for which the unrelated diagnosis and 

procedure are confirmed.

    (d) Review of DRG assignment. (1) A hospital has 60 days after the 

date of the notice of the initial assignment of a discharge to a DRG to 

request a review of that assignment. The hospital may submit additional 

information as a part of its request.

    (2) The intermediary reviews the hospital's request and any 

additional information and decides whether a change in the DRG 

assignment is appropriate. If the intermediary decides that a higher-

weighted DRG should be assigned, the case will be reviewed by the 

appropriate QIO as specified in Sec. 466.71(c)(2) of this chapter.

    (3) Following the 60-day period described in paragraph (d)(1) of 

this section, the hospital may not submit additional information with 

respect to the DRG assignment or otherwise revise its claim.

    (e) Revision of DRG classification and weighting factors. Beginning 

with discharges in fiscal year 1988, CMS adjusts the classifications and 

weighting factors established under paragraphs (a) and (b) of this 

section at least annually to reflect changes in treatment patterns, 

technology, and other factors that may change the relative use of 

hospital resources.



[50 FR 12741, Mar. 29, 1985, as amended at 52 FR 33057, Sept. 1, 1987; 

57 FR 39821, Sept. 1, 1992; 59 FR 45397, Sept. 1, 1994]