Edit Contract DRG Grouper

1. Access the Edit Contract DRG Grouper page.
   • Select Go To > Contract Loading > Contract Profile Management. The Contract Profile Management page opens.
   • Specify the selection criteria, and click Refresh View. The results appear.
     • The contract profile must be checked out by you before you can edit the DRG grouper version.
     • For more information about searching for a contract profile, refer to Manage Contract Profiles.
     • For more information about checking out a contract profile, refer to Check Out / Check In a Contract Profile.
   • Click a link in the Contract Name column. The Edit Contract Profile page opens.
   • Click Edit Contract DRG Grouper at the top of the page. The Edit Contract DRG Grouper page opens.
2. The Edit Contract DRG Grouper page displays each of the DRG grouper versions defined for this contract profile.
   • NEW in the Delete column indicates a new line where you can define a new grouper version for this contract profile.
   • You can only define one grouper version for a specific date range. To define a new grouper for the same date range, you must delete the existing grouper definition by selecting the Delete check box and clicking Update DRG Grouper List.
3. Select the type of DRG grouper you want to use for this contract profile from the DRG Grouper Type list.
   • AP-DRG
   • APR-DRG
   • MS-DRG
   • ICD-10 MS-DRG
   • TRI-DRG
4. Select the grouper version you want to use for this contract profile from the DRG Grouper Version list.
   • This list shows each DRG grouper version and the Medicare effective date available for the selected DRG Grouper Type.
   • For the MS-DRG grouper, select F* to always default to the most recent version of the grouper version.
   • You can select F* on multiple lines as long as the effective dates for those lines do not overlap.
   • For the TRI-DRG grouper, the TRI* option selects the appropriate grouper version based on the claim's date of discharge. The Grouper DRG Rules are the following:
     • Always - claim always groups and the grouper version used displays on the Reimbursement screen.
     • Never - claim never groups and No Grouper Version displays on the Reimbursement screen (only the claim DRG displays).
     • When DRG Blank - claim only groups if the claim DRG is invalid or missing, and the grouper version used displays on the Reimbursement screen.

5. Type the effective date for the DRG grouper version in the Effective Date field.
   • The effective date is the date this contract profile begins using this DRG grouper version to calculate reimbursement.
   • The effective date cannot overlap with another DRG grouper version definition.
   • The effective date cannot precede the Medicare DRG Grouper effective date.
   • You can also click the Calendar icon to select a date from the calendar.
6. Type the termination date for the DRG grouper version in the Termination Date field.
   • The termination date is the date this contract profile stops using this DRG grouper version to calculate reimbursement. If no other DRG grouper is defined, the contract profile will revert to the default DRG grouper version after this date.
   • You can leave this field blank to use this DRG grouper version from the effective date forward.
   • You can also click the Calendar icon to select a date from the calendar.
7. Select the patient type you want to apply this version of the DRG grouper version to from the Patient Type list.
   • Select IP to apply the DRG grouper version to inpatient claims only.
   • Select IP/OP to apply the DRG grouper version to both inpatient and outpatient claims.
8. Select the rules to apply to this version from the DRG Grouper Rules list.
   • Select Never to never override the DRG grouper to this version.
   • Select When DRG Blank to only override the DRG grouper to this version when the DRG is missing.
   • Select Always to always override the DRG grouper to this version for all claims repricing against this contract profile.
9. When the DRG Group Type is APR-DRG and the DRG Grouper Version is APR*, select the rules to apply to this version from the DRG Grouper Rules list.
   • Always – The DRG Grouper automatically selects the appropriate Grouper Version and HAC Version based on the claim date of service as well as the Effective Date and Effective Date Match settings of the DRG Grouper Information. The Grouper is set at the Contract level.
   • Never - The DRG Grouper does not regroup the claim. The Grouper is set at the Contract level.
   • When DRG or SOI is invalid - The DRG Grouper automatically selects the appropriate Grouper Version and HAC Version based on the claim date of service as well as the Effective Date and Effective Date Match settings of the DRG Grouper Information. However, the claim only groups if either the DRG or the SOI does not exist on the claim or has an invalid value. If the claim has valid values for both the DRG and the SOI, the DRG Grouper does not regroup the claim. The Grouper is set at the Contract level.
   • Per Data File – The claim groups based on the Grouper Version and HAC Version set in the Data File for the claim date of service. The Grouper is not set at the Contract Level.
10. Select the date you want to use to determine the DRG grouper for this contract profile from the Effective Date Match list.
    • Select ADMIT DATE to match the admission date to the DRG grouper effective date to determine which DRG grouper version to apply.
    • Select DISCHARGE DATE to match the discharge date to the DRG grouper effective date to determine which DRG grouper version to apply.
11. Select the Use POA option to determine if the Present on Admission (POA) indicator on the claim will be applied.
    • Select No to allow the grouper to ignore the POA indicator on the claim.
    • Select Both to allow the grouper to include the POA indicator on applicable claims while grouping and pricing.

    Select Both instead of Yes. Selecting Yes requires a POA to be included with the DRG. If Yes is selected but there is no POA billed, the grouper will return an error condition.

    On the UB04, the POA indicator is the eighth digit of the Principle Diagnosis field, Field Locater 67 (FL67), and the eighth digit of each of the Secondary Diagnosis fields, FL67 A-Q.

    • If the POA indicates a complication was acquired after admission, the DRG may change, resulting in a lower reimbursement.
    • The Use POA option is disabled for DRG grouper versions prior to 2008.
    • The Use POA option is disabled for all DRG Grouper Versions except F* when Never is selected from the from the DRG Grouper Rules list.
12. If the DRG Grouper Type is APR-DRG Grouper version APR26 or higher, select the Hospital Acquired Condition (HAC) version used for this contract profile from the HAC Version list.
    • This option is only available for contracts using APR-DRG Grouper version APR26 or later.
    • This field is automatically populated based on the DRG Grouper Version selected.
    • For versions prior to APR26, the HAC Version value will be blank.
13. If the DRG Grouper Version is APR* and the grouper version’s Effective Date and/or the HAC Version effective date is different from the CMS’s effective date, you must make the appropriate selection from the DRG Grouper Version State drop down list.
14. Click Update DRG Grouper List to save your changes.

The following table describes the fields on the Edit Contract DRG Grouper page .

• Edit Contract Profile returns to the Edit Contract Profile page. For more information, refer to Edit a Contract Profile.
• Contract Profile Management displays the Contract Profile Management page. For more information, refer to Manage Contract Profiles.