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APR-DRG

  ALL PATIENT REFINED DRGs

What does the four-digit APR-DRG represent?

Each stay is assigned first to one of 314 base APR-DRGs. Then, each stay is assigned to one of four levels of severity (minor, moderate, major or extreme) that are specific to the base APR-DRG. Severity depends on the number, nature and interaction of complications and comorbidities. For example, APR-DRG 139-1 is pneumonia, severity 1, while APR-DRG 139-2 is pneumonia, severity 2. Unlike MS-DRGs, there are no universal lists of complications and comorbidities or major complications and comorbidities.

For hospitals that choose to acquire APR-DRG software, staff should note that the software outputs the base APR-DRG and the severity of illness as two different fields. Medicaid concatenates these fields for purposes of calculating payment. The APR-DRG is therefore four bytes (ignoring the hyphen), in contrast to the three-byte CMS-DRG field. The Medicaid claims processing system is being enhanced to carry the four-byte DRG value and to output it to the X12N 835 electronic remittance advice.