All Patient Refined Diagnosis Related Group

ForwardHealth uses the All Patient Refined Diagnosis Related Group (APR DRG) classification system to classify and calculate pricing for inpatient hospital claims, Medicare crossover claims, and HMO encounters with dates of discharge or "To" dates of service (DOS) on and after January 1, 2017. The APR DRG classification system will replace the Medicare Severity Diagnosis Related Group (MS-DRG) classification system. The MS-DRG classification system is still effective for inpatient hospital claims, Medicare crossover claims, and HMO encounters with dates of discharge or "To" DOS before January 1, 2017.

Please see here for a history of the previously used MS DRGs.

The APR DRG classification system:

• Aligns the classification of inpatient hospital claims and HMO encounters more appropriately with the needs of the Medicaid, BadgerCare Plus, Wisconsin Chronic Disease Program (WCDP) – Adult Cystic Fibrosis, and WCDP – Chronic Renal Disease member populations.
• Expands the DRG system scope to include patient severity of illness and risk of mortality levels.
• Changes the pricing for inpatient hospital claims and HMO encounters for members enrolled in Wisconsin Medicaid and BadgerCare Plus.
• Changes the pricing for inpatient hospital claims for members enrolled in WCDP – Adult Cystic Fibrosis and WCDP – Chronic Renal Disease, which were not currently priced using the MS-DRG classification system.
• Excludes services provided to members enrolled in WCDP – Hemophilia Home Care.
• Excludes reimbursement for services provided at rehabilitation and psychiatric hospitals, which will continue to be reimbursed per diem as they are currently.
• Excludes services provided during certain types of hospital stays, including services related to ventilator care, certain unusual cases, and brain injury cases.
• Excludes inpatient hospital services provided to Department of Corrections inmates at acute care hospitals.