Section title: Requests for Interpretation
RFI #
2337
Report APR-DRG weight in 835
Description

RFI# 2166 provides a recommendation for reporting the APR-DRG code in Loop 2100, REF - Other Claim Related Identification segment. However the RFI does not address how to report the APR-DRG weight in the 835.
CLP12 is defined as DRG Weight. The CLP12 Situational Rule states: 'Required for Institutional claims when the claim was adjudicated using a DRG'. The rule does not specify a particular DRG associated with the weight. Can CLP12 be used to report the APR-DRG weight (or the weight of any other type of DRG) or is CLP12 limited to only reporting the weight for the MS-DRG reported in CLP11?
If CLP12 can't be used to report the APR-DRG weight, is X12's recommendation to append the weight with the APR-DRG code in the REF02 element (per RFI 2166), of the Loop 2100, REF - Other Claim Related Identification segment, when REF01=CE?

Response

Existing RFI 2166 provides information on reporting the APR-DRG, but does not address DRG Weight. In order to report DRG Weight for an APR-DRG reported in the REF*CE as outlined in RFI 2166, the workgroup recommends including the DRG Weight information in the REF02 along with the APR-DRG.

RFI Recommendation

The REF02 element supports 50 characters, allowing the payer to specify that they will identify their contract and the related applicable APR-DRG and DRG Weight using a format like "Contract - APR-DRG - DRG Weight". For example, if the line of business is "Premier PPO" , the APR-DRG is "12345", and the DRG Weight is "1.1234", then the value in REF02 would be reported as "Premier PPO - 12345 - 1.1234". As long as that doesn't exceed the 50 character maximum size, there should be no problem. Of course, the format and usage should be conveyed to providers via any trading partner agreement or companion guide.

DOCUMENT ID
005010X221A1