Interpret
Required when an inpatient hospital is under DRG contract with a payer and the contract requires the provider to identify the DRG to the payer. If not required by this implementation guide, do not send.
To mean
Required when an inpatient hospital provider is under DRG contract with a payer and the inpatient hospital provider’s DRG contract requires the inpatient hospital provider to identify the inpatient hospital provider’s DRG to the payer. If not required by this implementation guide, do not send.
Can I get an interpretation on the situational note. It says required when a hospital is under a DRG contract the contract requires the provider to identify the DRG, It’s the provider part that seems to allow it to be opened to other providers, we are doing a pilot where we will bypass prior hospital stay requirements for when the SNF accepts patients from hospitals for certain DRGs. It seems that based off the “Provider” that would mean the SNF should report this field if we so require?
No. The requirement to report the DRG is limited to the hospital under DRG contract and does not extend to other entities. The SNF can choose to supply the DRG as a claim note but cannot be required to supply the information.
After the pilot program has been evaluated and proved to be beneficial, submit a business case to allow SNF to submit DRG in the HI segment if the prior hospital stay is bypassed.