How to Bill for DRGs & Outlier Payments

Diagnostically Related Groups of procedures (DRGs) can include such circumstances as an inpatient stay followed by another inpatient stay.

Go to DRG Outlier Payments Guidelines

Go to DRG Readmissions Within 15 Days Guidelines

Go to DRG Transfer Guidelines

Services Considered Part of the DRG Payment
Certain services provided by facilities within 3 days of admission are considered part of the DRG (diagnostic related groups) and are not reimbursed separately. Those services include:

• Outpatient services followed by admission before midnight of the following day are treated as inpatient services and part of DRG.
• Diagnostic services (including clinical diagnostic laboratory tests) provided by the admitting hospital or entity owned by hospital within 3 days prior to admission are deemed inpatient services and included in DRG payment.
• Other preadmission services related to admission and provided within 3 days of admission are considered part of DRG.
• Emergency room services within 24 hours of admission are part of DRG.

Excluded from DRG Payment

• Diagnostic services rendered during ER visits 48 to 72 hours prior to admission are considered part of ER visit and are excluded from DRG payment.
• Ambulance services are not considered to be part of DRG payment.