difference between DRG and CPT

[FenderHM]

whats the difference between diagnostic-related groups for billing and Current Procedural Terminology for billing? help exam tomorrow

---

Members don't see this ad.

 

[Winged Scapula]

whats the difference between diagnostic-related groups for billing and Current Procedural Terminology for billing? help exam tomorrow

DRGs are a system to classify hospital cases into a diagnostic group for Medicare as part of the payment system. DRGs are used to determine how much Medicare pays the hospital, since patients within each category are similar clinically and are expected to use the same level of hospital resources. DRGs are also used to collect data on the number of patients with certain diagnoses and can be used to allocate resources (ie, if a hospital notices that they have many more patients readmitted with COPD, they may start to think about allocating more resources to outpatient Pulm clinics).

CPT are codes for procedures or operations done on patients. All patients will have a DRG, not all will have CPT codes.

As a surgeon, when I operate on someone I document the CPT code and that's how I get paid; the hospital documents their DRG and that's how they get paid. Of course, if I don't actually operate on someone (ie, admit for a post-op complication or other non-surgical reason), I don't submit a CPT code (but I still get paid for my services).

Hope that helps.

 

[FenderHM]

DRGs are a system to classify hospital cases into a diagnostic group for Medicare as part of the payment system. DRGs are used to determine how much Medicare pays the hospital, since patients within each category are similar clinically and are expected to use the same level of hospital resources. DRGs are also used to collect data on the number of patients with certain diagnoses and can be used to allocate resources (ie, if a hospital notices that they have many more patients readmitted with COPD, they may start to think about allocating more resources to outpatient Pulm clinics).

CPT are codes for procedures or operations done on patients. All patients will have a DRG, not all will have CPT codes.

As a surgeon, when I operate on someone I document the CPT code and that's how I get paid; the hospital documents their DRG and that's how they get paid. Of course, if I don't actually operate on someone (ie, admit for a post-op complication or other non-surgical reason), I don't submit a CPT code (but I still get paid for my services).

Hope that helps.

thanks!

 

[PediBoneDoc]

just a little correction. all patients will have a ICD (International Classification of Diseases) currently using ICD-9. all ICD's are associated with DRG's as well as permitted CPT's.

every patient (surgical or non-srugical) will be admitted with a ICD-9 diagnosis and may be discharged with the same or another. i have my residents code for the most generic ICD-9 diagnosis until formal diagnoses are made because of some of the longer term issues once a ICD diagnosis is attached to a patient it always follows them (even when proven that that is not the diagnosis, a significant problem with work comp). when codes incorrectly, that is when insurance companies will start to deny or permit test, days of hospital stay, and surgical procedures. upon discharge, the best way of maximizing DRG you should put all appropriate ICD-9 diagnoses (including post op anemia, post op ileus, etc).

 

[Winged Scapula]

Thanks for the clarification, Pedi...😀