All-Payer Severity-Adjusted DRGs® Overview

Familiar Methodology—Enhanced

APS-DRGs build off the MS-DRG structure used by the Centers for Medicare & Medicaid Services (CMS) for Medicare inpatient reimbursement. OptumInsight has generalized and enhanced the CMS methodology to make it applicable to all-payer (non-Medicare) patient populations. This classification system relies on administrative data routinely collected by hospital abstracting and billing systems.

Highlights

• Helps predict health care delivery costs based on how sick the patient is
• Provides the foundation for payers and providers to implement severity-adjusted reimbursement
• Is intuitively reasonable, clinically acceptable, and statistically powerful
• Makes use of a familiar, efficient, and flexible grouping algorithm

The APS-DRG Difference

The open architecture of APS-DRGs allows coders to understand how coding and management practices affect DRG assignment and payment. This transparency reveals the variables used to predict resource use and measure patient severity. APS-DRGs define severity classes based on clinical conditions, not treatment decisions, and measure severity based on patients’ diagnosed conditions rather than on procedures performed.

Three Main Components

The APS-DRGs Grouper is a resource-based methodology for classifying patients into meaningful clusters based on the degree of complication or comorbid condition observed during a hospital stay. The APS-DRGs Weight File is a data set containing weights appropriate for use with the APS-DRGs Grouper. The APS-DRGs Definition Manual provides a comprehensive guide to grouping cases into APS-DRGs.