Select high-dollar outlier exclusions

To accurately model changes made to the Inpatient CMS Centers for Medicare & Medicaid Services DRG Diagnostic Related Group. A statistical system of classifying any inpatient stay into groups for the purposes of payument. The DRG classification system divides possible diagnoses into more than 20 major body systems and subdivides them into almost 500 groups for the purpose of Medicare reimbursement. calculation, you may need to determine the high-dollar outlier exclusion amount. To exclude high-dollar charges like transplant acquisition charges or coagulation factors from the CMS DRG outlier determination, you can specify the Line Item codes or Rev Codes associated with these charges to exclude them from the outlier determination within the CMS DRG calculation. Use the Exclusions window when defining a provision for Medicare and Medicare-like contracts.

After selecting the exclusions, you add a clause or term with the CMS DRG calc basis The calculation basis is one of the elements that defines how a claim pays on a clause or term. The calc basis is used in conjunction with the calculation type and measure to determine a specific reimbursement method. In normal contract building rules, the Calc Basis is used to determine if a claim qualifies for the clause or term., and then attach DRGs and other required DRG-related elements. When incoming claims are processed against the CMS DRG calculation, if a claim has any CMS DRG items that match the clause or term on the provision, the system inspects the lines on the claim for the selected exclusion codes. The system totals any claim items that match the exclusion codes and then subtracts this amount from the total charges when determining the outlier portion of the CMS DRG calculation.

To specify high-dollar exclusions:

  1. Navigate to the desired provision.
  2. On the Provisions page, in the Factors column for the desired provision, click the Set button (or, to modify the provision, click View).

  3. At the bottom of the Factors window, click Outlier Exclusions.

    The Outlier Exclusions window opens.

  4. At the top of the window, select the exclude option:
    • Rev Code – Select exclusion items by rev code.
    • Line Item Code – Select exclusion items by line item code.

    NOTE: You can select only one option.

  5. In the lower half of the window, locate the item(s) to exclude, and then click the up arrow button () to the left of each item to move that item to the top half of the window, as shown in the following example.

  6. Click Save and Exit.