CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy MSIDRG and APR/DRG Mapping

This policy documents Blue Cross & Blue Shield of Rhode Island's operational methodology for mapping inpatient claims to MS-DRG and APR-DRG groupers, backfilling groupers for new ICD-10 codes, and how those mappings determine inpatient hospital reimbursement for Commercial and Medicare Advantage products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy MSIDRG and APR/DRG Mapping

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionPrior authorization not applicable for this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

OctoberMS-DRG grouper implemented each year

NoneMedical criteria required

Not applicablePrior authorization

May 2025; Sep 2024Provider updates published

Inpatient DRG Reimbursement Criteria

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For MS-DRG (Medicare Advantage), BCBSRI implements the most current MS-DRG grouper annually in October and uses the assigned weight to determine reimbursement unless the hospital contract specifies otherwise.

For Commercial APR-DRG, BCBSRI may add new ICD-10 diagnosis and procedure codes to prior APR-DRG versions (backfilling) and reimburses inpatient acute services based on the weight assigned to the specific mapped DRG and severity level unless the service is reimbursed on a per diem or negotiated case rate basis under the inpatient contract.

If an MS-DRG mapping became effective after the DRG weight version referenced in the hospital's contract, the claim will be reimbursed based on the weight assigned in its initial year in accordance with contract provisions.

For inpatient admissions with a discharge status of deceased, payment is the lower of the calculated DRG rate or the actual billed charges.

Benefits and reimbursement specifics may vary by group and contract; refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable coverage details.

Terminology

inv-04: MS-DRG — MS-DRG grouper

DefinitionMS-DRG grouper (Medicare Severity — Diagnosis Related Groups) used by BCBSRI to map inpatient claims to DRGs and identify the DRG weight for reimbursement.

Implementation scheduleBCBSRI implements the new MS-DRG grouper each year in October and references the most current MS-DRG version for federal Medicare reimbursement purposes.

Reimbursement ruleReimbursement follows the weight assigned to the mapped MS-DRG and severity level unless the service is reimbursed on a per diem or negotiated case rate basis in the hospital contract.

Contract timing noteIf a claim maps to an MS-DRG that became effective after the DRG weight version in the hospital's contract, the claim will be reimbursed based on the weight assigned in its initial year per contract provisions.

Deceased discharge ruleFor inpatient admissions with discharge status of deceased, payment is the lower of the calculated DRG rate or the actual billed charges.

inv-05: APR-DRG — APR-DRG grouper

DefinitionAPR-DRG grouper (All Patient Refined Diagnosis Related Groups) used by BCBSRI for Commercial inpatient mapping and reimbursement.

Code updates/backfillBCBSRI's APR-DRG grouper software is periodically updated to add new ICD-10 diagnosis and procedure codes and may map those codes to prior APR-DRG versions (backfilling).

Reimbursement ruleReimbursement for inpatient acute services follows the weight assigned to the specific mapped APR-DRG and severity level unless the service is reimbursed on a per diem or negotiated case rate basis in the inpatient contract.

Contract variabilityBenefits and reimbursement may vary by group and contract; refer to the applicable Benefit Booklet, Evidence of Coverage or Subscriber Agreement for specifics.