Solventum™ All Patient Refined Diagnosis Related Groups (APR DRGs) Classification System

The Solventum APR DRG methodology classifies hospital inpatients according to their reason for admission, severity of illness and risk of mortality.

Solventum APR DRGs are used by payers, hospitals and researchers. Payers often use Solventum APR DRGs as the basis for an inpatient prospective payment method and as the risk adjustor in measuring hospital quality. Hospitals often use Solventum APR DRGs in combination with Solventum reimbursement calculation software to predict and verify expected reimbursement. Hospitals and researchers use Solventum APR DRGs to understand utilization, measure quality and calculate efficiency measures such as risk-adjusted cost per stay.

Here are a few examples of how the Solventum APR DRG patient classification methodology can bring value to health care organizations.

• Appropriate payment incentives. Implementing a Solventum APR DRG payment method rewards efficiency, because payment does not depend on hospital-specific costs or charges. At the same time, a Solventum APR DRG payment method creates incentives to increase access to care, because higher severity Solventum APR DRGs receive higher payment rates.
  
  
• Predict and verify expected payment. Solventum makes available reimbursement calculation software that enables providers to predict and verify expected payment using a specific payer’s Solventum APR DRG pricing policy.
  
  
• Public reporting. Because Solventum APR DRGs define “the product of a hospital,” they are useful in public reporting and other comparisons across hospitals and states. New York state, for example, uses Solventum APR DRGs to report average charges and costs for every hospital in the state.
  
  
• Quality comparisons. Solventum APR DRGs have been used in multiple analyses as the risk adjustor to make fair comparisons across hospitals on quality measures such as mortality, potentially preventable complications and potentially preventable readmissions.
  
  
• Clinical insight. Hospitals, state agencies, payers and researchers use Solventum APR DRGs to yield insights about clinical care. For example, analysis in multiple states has quantified the sharp inverse relationship between birth weight and the hospital’s cost of neonatal care.
  
  
• Financial analysis. Hospitals, state agencies, payers and researchers use Solventum APR DRGs to risk adjust measures such as charges, hospital cost and average length of stay to create fair comparisons of utilization and efficiency across service lines, hospitals and other populations.
  
  
• Defining episodes. The event of an inpatient stay is used in the Solventum™ Potentially Preventable Events (PPEs) Classification System to define an episode of care that includes the inpatient stay, the associated hospital and professional services, and related post-discharge services (such as rehabilitation).

Solventum APR DRG grouping logic is the same for every payer, although different payers choose different configuration options and may follow different update schedules. Each payer that uses Solventum APR DRGs makes its own decisions about prices and payment policies. For hospitals, other providers, health plans and other organizations that seek to understand, predict and verify expected payment, Solventum makes available software that emulates payer-specific grouping, pricing and payment policy. As of 2021, this payment prediction software is available for approximately 30 payers nationwide.

Solventum also makes available reimbursement calculation software for national payers that do not use Solventum APR DRGs, including Medicare DRGs and TRICARE DRGs.

Solventum APR DRGs are integrated with other Solventum patient classification methodologies.

Solventum has aligned the service line definitions between Solventum APR DRGs for inpatient care and the Solventum™ Enhanced Ambulatory Patient Groups (EAPGs) Classification System for outpatient care. This alignment allows analysis of charges, cost, payment and utilization by service line across both inpatient and outpatient settings.

Solventum APR DRGs are used to risk adjust the Solventum™ Potentially Preventable Complications (PPCs) Classification System and Solventum™ Potentially Preventable Readmissions (PPRs) Classification System methodologies. Solventum PPCs measure the incidence of a wide range of inpatient complications while Solventum PPRs are a well-accepted measure of the quality of both inpatient care and post-discharge follow-up in the community.

Solventum APR DRGs are used to define Solventum™ Potentially Preventable Admissions (PPAs) Classification System, which are a measure of population health.

Solventum APR DRGs are used to define certain Solventum PFEs. For example, Solventum APR DRG 301-1 Hip Joint Replacement triggers Patient-focused Episode 3011 Hip Replacement Procedure.

Solventum APR DRGs are available in the following Solventum products:

• Solventum™ 360 Encompass™ System
• Solventum™ Physician Coding and Reimbursement System (PCRS)
• Solventum™ Advanced CDI Transformation Program
• Solventum™ Clinical Documentation Improvement Solution
• Solventum™ Reimbursement Calculation Software
• Solventum™ Core Grouping Software (CGS)
• Solventum™ Grouper Plus Content Services (GPCS)
• Solventum™ Data-to-Action (DTA) Solution
• Solventum™ All Patient Refined Diagnosis Related Groups Software (APR DRG) for IBM® z/OS® Mainframe

Licensees of the Solventum APR DRG methodology have access to the following documents on the Solventum customer support website:

• Solventum™ APR DRG Methodology Overview
• Solventum™ APR DRG Summary of Changes
• Solventum™ APR DRG Definitions Manual
• Solventum™ APR DRG Software Installation and User’s Guide
• Solventum™ APR DRG Weights and Trims with Code Descriptions

Solventum experts are available to advise provider organizations, health plans, government agencies and other interested parties on how to obtain maximum value from using the Solventum APR DRGs. For example, Solventum consultants can help hospitals implement clinical documentation integrity (CDI) programs and use Solventum APR DRGs to measure and improve their own cost efficiency and quality of care. Solventum consultants can also help payers design payment methods based on Solventum APR DRGs and demonstrate how to use Solventum APR DRGs to understand patterns of utilization, charges, cost and payment.

The unit of analysis is an inpatient stay at an acute care hospital. All the data required to assign a Solventum APR DRG can be obtained from a standard inpatient hospital discharge record, such as the UB-04 form or the X12N 837I electronic transaction. Data fields that are particularly important for Solventum APR DRG assignment include all diagnosis codes, present on admission indicators, ICD-10-PCS procedure codes and procedure code date.

Solventum APR DRGs were first released in 1991. The Solventum APR DRG logic uses claims data to assign patients to one of 332 base Solventum APR DRGs that are determined either by the principal diagnosis or, for surgical patients, the most important surgical procedure. Each base Solventum APR DRG is then divided into four severity of illness (SOI) levels, determined primarily by secondary diagnoses that reflect both comorbid conditions and the severity of the underlying illness, creating the final set of 1,330 Solventum APR DRGs. The Solventum APR DRG logic computes both an admission severity of illness and a discharge severity. The present-on-admission (POA) indicator for each secondary diagnosis is a required data field for computing the severity of illness at the time of admission.

For example, Solventum APR DRG 139-1 is Other Pneumonia, severity of illness 1 (minor) while Solventum APR DRG 139-4 is Other Pneumonia, severity of illness 4 (extreme). Each base DRG also has four risk-of-mortality levels. Although severity of illness is often correlated with risk of mortality, the two concepts are different and it is possible for a patient to have a high severity of illness but a low risk of mortality. Acute cholecystitis is an example.

The clinical logic is maintained by a team of Solventum clinicians, data analysts, programmers and economists. The logic is proprietary to Solventum but is available for licensees to view in an online definitions manual.

Each year Solventum calculates and releases a set of statistics for each Solventum APR DRG based on our analysis of large national data sets. These statistics include a relative weight for each Solventum APR DRG. The relative weight reflects the average hospital resource use for a patient in that Solventum APR DRG relative to the average hospital resource use of all inpatients. Please note that payers and other users of the Solventum APR DRG methodology are responsible for ensuring that they use relative weights that are appropriate for their particular populations. The Solventum APR DRG statistics also include data for each Solventum APR DRG on relative frequency, average length of stay, average charges and incidence of mortality.

Solventum APR DRGs can be rolled up into broader categories. The 332 base DRGs roll up into 25 major diagnostic categories (MDCs) plus a pre-MDC category. An example is MDC 04, Diseases and Disorders of the Respiratory System. As well, each Solventum APR DRG is assigned to a service line that is consistent with the outpatient service lines that are defined by the Solventum™ Enhanced Ambulatory Patient Groups (EAPGs) Classification System. An example is service line 01.7, General Medicine – Pulmonary.

Solventum releases a new version of the Solventum APR DRGs every October 1, to reflect updates in the ICD-10 diagnosis and procedure code sets and to include enhancements to the clinical classification logic.