DRG-PC For XP/Win7

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DRG-PC For XP/Win7 is a DRG Calculation, Analysis, and Reimbursement Calculation application for:

  • Hospital medical records
  • Claims processing applications
  • Data Warehousing and data analysis
  • Claim review and compliance auditing
  • Re-pricing and much more

DRG-PC For XP/Win7 is ICD-10 ready and includes rich features for DRG Calculation and Reimbursement Optimization. The unparalleled flexibility of DRG-PC with multiple input/output modes, Interactive, Batch, and command-line processing modes make it the ideal tool for any health care environment.

DRG-PC For XP/Win7 is available in multiple formats:

  • Standard version - contains 2 years of DRG calculation specifications
  • Enhanced Version - contains 5 years of DRG calculation specifications

Request a Free 30-day Trial Version of DRG-PC For XP/Win7

PRICERActiveMedicare Reimbursement Components have been integrated with DRG-PC For XP/Win7 to implement the full Medicare Inpatient PPS DRG Reimbursement capability. Calculate the acute-care Medicare reimbursement, including cost outliers where applicable, for any Medicare hospital in the U.S.! Request a Free 30-day Trial Version of DRG-PC with PRICERActive to download.

Features of DRG-PC For XP/Win7:

DRG Calculation
DRG Reimbursement Calculation System
Batch Processing/Data Interface Capabilities
Output Options
Case History Log
Data Validation
Length of Stay Computation
Error Processing Subsystem
Data Entry Modes
DRG Processing Modes
DRG Weight/Reimbursement Analysis
Multiple Updateable DRG Weight Tables
DRG-PC Reports
DRG/MDC Reference
Help Screens
System Requirements

DRG-PC For XP/Win7 is simply the most versatile DRG Calculation software available today!

DRG Calculation

The Diagnosis Related Group (DRG) is the primary component of health care claims reimbursement determination for Medicare. DRG specifications are produced and maintained by the Centers for Medicare and Medicaid Services (CMS), a division of the U.S. Dept of Health and Human Services. Patient information including age, sex, and discharge status along with detail diagnosis and procedure code data from the patient record are processed through a complex algorithm to calculate the DRG. Associated with each DRG are weighting factors and statistical averages for the length of stay in an inpatient hospital. These data, when combined with hospital-specific cost factors are used to compute Medicare reimbursement for a hospital stay. For FY08 and after beginning with discharge dates of 10/1/07, DRG-PC incorporates the Medicare Severity DRG (MS-DRG) as mandated by CMS.

DRG-PC For XP/Win7 is a complete system for the calculation and analysis of the Diagnosis Related Group (DRG) and includes 2 fiscal years (optionally five fiscal years) of DRG specifications. Analysis features like DRG Weight Optimization show the coding and pricing options present with a case. Medical records personnel or claim reviewers can use DRG-PC to assure that claims will have the appropriate reimbursement from Medicare, an HMO/PPO or other payer. The built in reimbursement calculation system will compute an estimated reimbursement for each case. The PRICERActive DRG Reimbursement option is available for computing detail Medicare reimbursement for any of the Medicare hospitals in the U.S.

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DRG Reimbursement Calculation System

DRG-PC For XP/Win7 calculates an estimated reimbursement for each case processed. Reimbursement is calculated using the DRG Weight and the facility Blended Rate. Per Diem amounts are calculated for cases with an 02 discharge status. Encoder-Plus maintains multiple rate iterations, each with an effective date, for accurate pricing. Total charges are entered for each case and Encoder-Plus will calculate the variance between reimbursement and charges.

Optional PRICERActive™  plug-in component that is available for DRG-PC For XP/Win7 duplicates the reimbursement calculations used by Medicare for inpatient hospital claim payment. PRICERActive™ uses the same formulas and Medicare hospital-specific data that the Medicare intermediaries use to calculate claim payments and calculates all components of a Medicare PPS payment including:

  • Federal Specific Portion
  • Hospital Specific Portion (where applicable)
  • Capital-related Portion
  • Cost Outlier Portion
  • Indirect Medical Education Adjustment
  • Disproportionate Share Adjustment
  • New Technology Add-On
  • Low Volume Provider Adjustment
  • Hospital Readmission Reduction
  • Value-based Purchasing Adjustment
  • Uncompensated Care Amount
  • HAC Reduction Amount

With the PRICERActive™ option DRG-PC For XP/Win7 can calculate detail DRG payments for any Medicare hospital in the U.S. The PRICERActive™ option can also be set to compute Medicare reimbursements according to the rules for a Medicare HMO.

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Batch processing/Data Interface Capabilities

DRG-PC For XP/Win7 includes powerful features for importing and exporting data from other applications and performing batch processing. These features provide flexibility and adaptability to virtually any environment. DRG-PC For XP/Win7 can accept data directly from a number of database and spreadsheet programs including Microsoft Access, Microsoft Excel, Lotus 1-2-3, and dBase. In addition, DRG-PC For XP/Win7 accepts comma-delimited files that can be created from many other types of software including Microsoft SQL Server or Oracle databases.

One of the chief data interface mechanisms in DRG-PC For XP/Win7 is our Input/Output (I/O) Format Builder. This powerful feature allows DRG-PC For XP/Win7 to be easily customized to accept data in the format you already have instead of having to develop a specialized interface. Output data formats can be customized to the data file format of another application making it easy to pass DRG results data on to other systems or data repositories. Data files can be exported to database or spreadsheet programs for further analysis or reporting. These powerful but easy-to-implement features make DRG-PC For XP/Win7 a very powerful tool.

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Output Options

DRG-PC For XP/Win7 offers multiple Output Options for maximum flexibility. Processing results can be directed back to the screen, printed, or formatted into a data file that can be passed to other systems and applications, data repositories, etc.

The Data File Output option allows the user to export data in a formatted file. This data can be passed to other applications. The output filename extension determines how the file will be processed. The following associations are made between filenames and file types:

  • .MDB: Microsoft Access Database
  • .ACCDB: Microsoft Access Database
  • .CSV: comma-delimited file format
  • .XLS: Microsoft Excel spreadsheet
  • .XLSX Microsoft Excel spreadsheet
  • as well as a native ASCII file format for the claim type

Interactive Mode Screen Displays list all codes, descriptions, DRG detail results, and reimbursement amounts for the case being processed. Also edit error messages, if any, will be displayed on screen.

Printed Reports are available for DRG cases from all entry and processing modes.

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Case History Log

DRG-PC For XP/Win7 includes an optional Case History Log that maintains detail of all cases processed. Numerous options are available for selecting and displaying data by patient or date criteria. Complete detail for an individual case is available by double clicking the desired record. Data in history can be selected and exported to other applications, printed reports can be generated, and cases can be re-processed.

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Length of Stay Computation

DRG-PC For XP/Win7 will compute the Length of Stay (LOS) for each DRG discharge case. After the admission and discharge dates are entered on the data entry screen, the LOS is computed. The LOS is displayed on all DRG-PC output screens, reports, and is carried through to the output file generated from the File Output Option. DRG-PC computes the LOS just as Medicare will, the number of days between admission and discharge, not counting the day of discharge.

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Data Validation

DRG-PC For XP/Win7 incorporates complete validation of all data elements. Patient age, sex, discharge information, and a principal diagnosis are required for each case. All diagnosis and procedure codes are edited to be valid ICD9/10 codes. Additional Medicare Code Edits are performed to validate diagnosis and procedures codes against patient age and sex. Diagnosis and procedure codes are edited for being applicable only to male or female patients. Diagnosis codes that fall into categories of newborn, pediatric, maternity, and adult diagnoses are validated against the patient age. A series of edits are also performed to exclude manifestation codes, non specific codes, and E-codes as principal diagnosis. All the above edits are performed to Medicare specifications. The effect of this data validation is to help the user produce more accurately coded cases which will be paid in a more timely manner.

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Error Processing Subsystem

DRG-PC For XP/Win7 includes an error processing subsystem to help resolve difficult edit errors. If an error occurs that cannot be immediately resolved, it can be written to an internal error file for later resolution. This facility saves re-keying data and serves as a tracking mechanism for cases in process. Cases can be recalled from the error file to be re-processed after further research or verification is performed. Case profiles can be printed and unwanted cases can be deleted from the error file.

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Data Entry Modes

DRG-PC For XP/Win7 incorporates multiple data entry to provide flexibility and adaptability to many environments. These data entry modes are summarized below:

DRG Single Case Entry Mode

Single Case Entry Mode allows the user to enter and process a single patient discharge. Data is entered via the screen and is edited for validity. Help information, including data edit specifications, is available for each field on the data entry screen . After data has been entered and validated, DRG processing is performed. Processing is performed in Interactive Mode. DRG analysis options include Automatic DRG Weight Optimization or standard DRG processing. Once DRG processing is complete, the user can edit and re-process the case or proceed to the next. From Single Case Entry Mode the user can print a Detail Report for the completed case.

DRG Multi-Case Entry Mode

Multi-Case Entry Mode allows the user to enter and process multiple patient discharges. Data is entered via the screen and is edited for validity. Help information, including data edit specifications, is available for each field on the data entry screen. After all cases have been entered and validated, DRG processing is performed. Multiple processing options permit the user to process cases interactively or in a batch mode. DRG analysis options include Automatic DRG Weight Optimization or standard DRG processing. Once DRG processing is complete, the user can edit and re-process the case or proceed to the next. The file output option allows the user to export data. Multi-Case Entry Mode has report options of the DRG-PC Summary Report and Detail Report for each case.

File Input Entry Mode

File Input Entry Mode allows the user to enter and process multiple DRG cases. Data is entered from an ASCII file formatted by another application or computer system. The user must specify the drive, path, and filename of the input file. After records are loaded, all input data is edited for validity and processing begins. Multiple processing options permit the user to process cases interactively or in a batch mode.

For DRG cases, DRG analysis options include Automatic DRG Weight Optimization or standard DRG processing. Once DRG processing is complete, the user can edit and re-process the case or proceed to the next.

The file output option allows the user to export data. File Input Entry Mode has report options of the DRG-PC Summary Report and Detail Reports for each case.

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DRG Processing Modes

DRG-PC For XP/Win7 can operate in three different modes: Interactive, Batch, or Command line modes. These three processing modes provide differing capabilities allowing the user to utilize DRG-PC in different ways.

Interactive Mode

DRG-PC includes a feature called Interactive Case Analysis. This powerful feature is available from all data entry modes and is the default selection from DRG Multi-Case and File Input Entry Modes. This feature gives the user the ability to perform optimization analysis on each discharge case. Data elements can be modified and the case can be re-processed until desired results are achieved. This unique feature along with Automatic DRG Weight Optimization gives the user a powerful set of tools to maximize the DRG reimbursement. The full range of DRG-PC printed reports are available from Interactive Mode.

Batch Mode

DRG-PC provides a batch processing function for volume processing of cases. Data can input either through Multi-Case or File Input Entry Mode. Case processing then takes place with no user intervention. Output can be directed back to the screen, sent to a data file to serve as input
to another application or data repository, or printed on DRG-PC Reports.

Command Line Mode

DRG-PC DRG calculation can be invoked directly from the DOS command line. This processing mode takes advantage of the DRG-PC File Input and File Output functions. DRG-PC will input an existing formatted data file, perform editing and DRG calculation, and write results to a user-specified output file without any user interaction. In this way, DRG-PC processing can be executed from a DOS Batch file in conjunction with other PC applications. This option makes it possible to download formatted data from another computer, process the file through DRG-PC, and upload the results back to another computer for updating files. Options to this process include the selection of printed reports and selection of Automatic DRG Weight Optimization or standard DRG processing.

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DRG Weight/Reimbursement Analysis

DRG-PC For XP/Win7 includes features for Reimbursement and DRG Weight optimization, available through all data entry modes. This process will assure the highest possible reimbursement.

DRG-PC offers an Automatic DRG Weight optimization function. Each diagnosis code entered will be processed as the principal diagnosis, and the code that returns the highest weight factor will be retained. Each entry mode offers the ability to edit and re-process the discharge case. During re-edit, the user can re-order the codes and reprocess to find the highest weight.

A complete Optimization Results Tracking system helps you manage the different combinations that help you determine the optimal reimbursement. Advanced Analysis Options allow you to further subdivide the data in the case and examine alternatives that may lead to higher reimbursement. Optimization Detail reports and a DRG Worksheet can be printed to shoe the results of the optimization activity.

A DRG Check feature examines the specifics of the DRG and MDC that has been selected and will notify you if other reimbursement optimization alternatives are possible.

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Multiple Updateable DRG Weight Tables

DRG-PC For XP/Win7 contains a feature that allows the user to update alternate DRG Weight Tables used in the reimbursement calculation process. The Medicare DRG weight tables are standard and two additional updateable DRG Weight Tables are available. The individual DRG weights and average length of stay values can be updated for each DRG. The title you assign to each table can also be updated. These alternate DRG weight tables can be used for any other payer. This feature provides great flexibility for reimbursement calculation among many payers. The selection of the DRG Weight Table to be used in pricing, is made under the Blended Rate Entry/Update function.

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DRG-PC Reports

DRG-PC produces multiple types of printed reports. Details of each report are listed below. DRG-PC For XP/Win7 supports all Windows-supported printers.

Detail Report: DRG-PC will produce a detail report containing all input data and processing results. The detail report includes all codes, descriptions, DRG/APC/ASC detail results, and reimbursement amounts for the case being processed. Also edit error messages, if any, will be printed. An optional certification statement and signature block can be included for physician certification.

DRG-PC Summary Report: DRG-PC will produce a summary report from either the Multi-Case or File Input entry Modes. This report prints two lines of data for each case processed. All of the significant data elements are included. If any errors have occurred during batch type processing, detail error messages are printed.

DRG Worksheet: This report describes all of the reimbursement alternatives based on the various diagnosis code combinations explored during the optimization process. The worksheet can then be given to a physician to make the final determination of principal diagnosis based on the medical condition that occasioned the admission.

Optimization Detail Report. This report provides the detail information for each diagnosis code combination tried during the optimization process. The report shows the results of each diagnosis code being tried as the principal diagnosis and includes the DRG Weight, reimbursement, all diagnosis code, DRG and MDC descriptions.

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DRG/MDC Reference

DRG-PC For XP/Win7 includes an on-line reference to descriptions of all DRG’s and MDC’s (Major Diagnostic Category). This reference is available from the main menu. The desired DRG number is entered and the corresponding description is displayed in a viewing window. The user can then scroll the display to view other DRG descriptions. A search function is available to find a specific DRG.

The MDC display shows each MDC description. The display can be scrolled in order to view all MDC descriptions.

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Help

DRG-PC For XP/Win7 includes a comprehensive Help file to describe the features of the software.

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System Requirements

  • DRG-PCFor XP/Win7 has been designed for a single user to run on a Microsoft Windows 2000/XP/Vista/7 desktop PC.
  • Administrative privileges on the system are required for installation, but DRG-PC runs under a regular Windows User privilege.
  • Pentium IV-class PC (1 GHz or higher recommended)
  • 256 MB of RAM or more (1 GB or more recommended)
  • 90 MB of hard drive space required for maximum product configuration. Additional hard drive space required to store case history data (optional, but default is On).
  • Designed for a screen resolution of 800x600 or 1024x768
  • Mouse or other compatible pointing device

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