Add Diagnosis Related Group (DRG) Code

This rule will instruct the system to include Diagnosis Related Group (or DRG) code(s) on institutional claims. 

Workflow

Let's review how to create a claim rule to include a DRG code to a claim!

• 1. Navigate to Management Center > Claim Rules.
     
     
  2. Click Create Claim Form  Rule.
     
  3. Select the Practice.
     
  4. Next, give the rule a name.
  5. Update the Claim Type to Institutional or Professional.
     
  6. Select Conditions to create criteria a claim should meet before the rule will apply.
     
  7. Next, click on the Behaviors dropdown.
  8. Select DRG Code.
     
     
  9. Next, click Add.
     
  10. Input the desired DRG Code.
      
  11. To create multiple behaviors, repeat steps 7-10.
  12. Click Save to complete the process.
       

Box Number(s)

• UB-04: Box 71 - PPS Code
• CMS-1500: N/A

Helpful Hints

•  DRG codes are the diagnosis-related group codes. Each DRG has a payment weight assigned to it. Payment weights are affected by factors such as:

  • • geographic location (cost of living adjustment factor),
    • the number of low-income patients in that location (DSH adjustment),
    • whether that facility is a teaching facility (IME adjustment), and
    • if this is an outlier case (a particularly costly case).
• If one of your conditions is payer-based, select Current Sequence Behavioral instead of the Primary Behavioral Payer. This will ensure the rule applies to secondary and tertiary claims when needed. 
• To read more about how to set claim rule conditions and order, see the Claim Rule: Setting Claim Rule Conditions article.
• To read more about how to set up a claim rule to be effective as of a certain date, see the Scheduled Change Sets article.