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CODER GLOSSARY Blended Rate: The average rate for all DRGs in a given hospital, defined by Federal regulations and adjusted annually for inflation, technical changes, and budgetary constraints. There are also adjustments for hospital size, local wage variations, teaching hospitals, and proportion of indigent patients. Case Mix Index (CMI): The average weight for all of a hospital's Medicare volume. It reflects the relative severity of the patient population at that hospital. Coder: A trained hospital professional who assigns codes to diagnoses (ICD-9 codes) and procedures (ICD-9-CM and CPT codes) for the purpose, among others, of determining Medicare payment for services rendered to each patient. Coding: The process based on the attending physician's entry of diagnosis and procedures in the patient's record, which are encoded by hospital personnel using ICD-9-CM nomenclature and the "grouper" program to assign the patient's DRG. Diagnosis Related Group (DRG): A classification for each patient based on clinical information. The DRG determines a flat rate paid to the hospital, regardless of actual services provided. Over 490 DRG categories are defined by the HCFA. Grouper: A computer program which processes coded Medical Record data to determine the DRG for each patient. Pertinent data are: -Principal Diagnosis -Complications and Comorbidities (secondary diagnoses) -Surgical Procedures -Age -Gender -Discharge Disposition (routine, transferred, or expired) Health Care Financing Administration (HCFA): The Federal agency that keeps DRG classifications up to date, maintains the ICD-9-CM coding scheme, and assigns a relative weight to each DRG, based on its average cost in the prior year compared to the overall average. The relative weight list appears each year in the Federal Register. ICD-9-CM: A numerical coding scheme of over 13,000 diagnoses and 5,000 procedures. Outlier: A patient excluded from a DRG because of exceptionally high costs. Peer Review Organization (PRO): An organization designated for each state to ensure that hospitals comply with regulations and do not compromise care to save money. A PRO may deny Medicare payment for admissions deemed unwarranted. Prospective Payment System (PPS): A system of Medicare where hospitals are paid a pre-determined rate for each Medicare admission, the average for that patient's DRG. Weight: The factor applied to a hospital's average payment rate to determine payment for a particular DRG category. DRG PAYMENT = WEIGHT X RATE -- J. R. Bruman (818) 789-3694 3527 Cody Road Sherman Oaks, CA 91403-5013