An overview

CASEMIX

1
 Case-mix is a classification of patients
treatment episodes designed to create classes
which are relatively homogenous in respect of
the resources used and contain patients with
similar clinical characteristics;
characteristics refers to the
range and types of patients a hospital treats

(George Palmer, Beth Reid)

2
Health Facility

3
Contact with Obstetrics Endocrine/
Mental
Health Conditions Metabolic
Illness (F)
Facilities (Z) (O) Diseases (E)

Neoplasms
Genetic Gynecological
Injury/ Trauma (C, D)
Disorders (Q) Diseases (N)
(S,T) 4
CASEMIX CLASS/GROUP

CLINICAL CHARACTER ; $
CONSUMED
 each DRG is allocated a weight, which is dependent on the
average cost of inputs (e.g. nursing, diagnostic services,
procedures) required to achieve the appropriate patient outcome.

serves as an information tool that allows policy makers

understand the nature and complexity of health care delivery

the facility is reimbursed a predetermined amount for each

patient episode.

a system that measures hospital performance,

performance aiming to
reward initiatives that increase efficiency in hospitals.
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 Payment of hospitals
Use of Casemix
the evolution In 1980 New Jersey
become the first state
to adopt DRGs to pay
hospitals to address
weak cost control
In 1983 DRGs adopted
Comparing and nationally by the U.S.
Medicare system as
benchmarking the PPM for hospitals
hospitals

Classification
system for patients
(Hospital Output)

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 Stew on this

MALAYSIANDRG

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 MOH in-patient casemix is called
MalaysianDRG

5-digit numbering system

1st 2nd 3rd 4th 5th
digit digit digit digit digit

MDC DRG SOI

25 966 IP-3; OS-2; OM-0

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MalaysianDRG

Clinical Module Costing Module EIS/BI Maintenance User Manual

MASTER DETAIL
COLUMN COLUMN
 PRINCIPAL DIAGNOSIS (ICD-10:14,500+)

MAJOR DIAGNOSTIC CATEGORIES (MDC: 24 GROUPS)

1

SURGICAL PROCEDURE (ICD-9-CM: 3,500+)

NO YES

2
MEDICAL SPLIT 2
SURGICAL SPLIT
PRINCIPAL DIAGNOSIS
TYPE OF SURGERY
Neoplasms, Specific Conditions
Major, Minor, Other unrelated Dx
Symptoms, Others

COMPLICATIONS, CO-MORBIDITY, 3AGE SPLIT

4
DIAGNOSIS RELATED GROUPS (DRG: 726) 12 12
 Highest level of aggregation of patient (diagnosis) mix is called Major
Diagnostic Categories (MDC)
In-patient Service 24 MDC
Out-patient Service 1 MDC

MalaysianDRG classifies acute inpatient episodes into 966 categories

based on clinical conditions and resource consumption
In-patient 729 DRGs

Out-patient 237 DRGs

13
 Highest level of aggregation of patient (diagnosis) mix is called Major
Diagnostic Categories (MDC)
In-patient Service 24 MDC

Out-patient Service 1 MDC

MalaysianDRG classifies acute inpatient episodes into 966 categories

based on clinical conditions and resource consumption
In-patient 729 DRGs

Out-patient 237 DRGs

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 For every DRG, it is further sub-classify to 3 several Severity of Illness
(SOI)
In-patient 3
SOI 1 : Without co-morbidity & complication (W/O CC)
SOI 2 : With co-morbidity & complication (W CC)
SOI 3 : With Major co-morbidity & complication (W MCC)

Out-patient (Surgical) 2
SOI 1 : Simple
SOI 2 : Complex

Out-patient (Medical) 0
there is no Severity of Illness for OP (Medical)

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 MDC 01 MDC 02 MDC 03 MDC 04 MDC 05 MDC 06
DRG
DRG DRG DRG DRG DRG DRG DRGDRG DRG DRG DRG
DRG DRG DRGDRG DRG DRG DRGDRG DRG DRG DRG
DRG DRG DRG DRG DRG DRG DRG DRG DRG
DRG DRG DRG DRG DRG DRG
DRG DRG DRG DRG
DRGDRG DRG DRG DRG DRG DRG DRG DRGDRGDRG DRG DRG
DRG DRG
DRG DRG DRG DRG DRG DRG DRG DRG
DRG DRGDRGDRG DRG DRG DRG
DRGDRGDRGDRG DRG DRG DRG DRG DRG DRG
DRG DRG DRG DRG DRG
DRG DRG DRG DRG DRG DRG DRG DRG DRG
DRG
DRG DRGDRG DRG DRG DRG DRG DRG DRG DRG DRG
DRG DRG DRG DRG DRG DRG DRG
DRG DRG DRG DRG DRG DRG DRG DRG
DRG DRG DRG DRG DRG
DRG DRG DRG DRG DRG DRG DRG DRG DRG DRG
DRGDRG DRG
DRG DRG
DRG DRG DRGDRG DRG DRGDRG DRG DRG DRG
DRG
MDC 07 MDC 08 MDC 09 MDC 10 MDC 11 MDC 12
DRG DRG DRG DRG
DRG DRG
DRG DRG DRG DRGDRG DRG DRG DRG DRG DRG DRG DRG DRG DRG
DRG DRG DRGDRGDRG DRG DRG
DRG DRG DRG DRG DRG DRG DRGDRGDRG DRG DRG DRG
DRG DRG DRG DRG DRG
DRG DRG
DRG DRGDRG DRG DRG DRG DRG DRG
DRG DRG DRG
DRG DRG DRG DRG DRG DRG DRG DRG DRG DRG DRG
DRG DRG DRG DRGDRG DRG DRG DRG DRG DRG
DRGDRGDRGDRG DRG
DRG DRG DRGDRG DRG DRG DRG DRG DRG
DRG DRG DRG DRGDRG
DRG DRG DRG
DRGDRGDRGDRG DRG DRG DRG DRG DRG DRG DRG DRG

MDC 13 MDC 14 MDC 15 MDC 16 MDC 17 MDC 18

DRG DRG
DRG DRG DRG DRG DRG DRG DRG DRG DRG
DRG DRGDRG DRG DRG DRG DRG DRG DRG DRG
DRG DRGDRG DRG DRG DRG DRG DRG DRG
DRG DRG DRG DRG DRG DRG DRG
DRG DRG DRG DRG DRG DRG DRG DRG DRG DRG DRG
DRG DRG DRG DRG DRG
DRG DRG DRG DRG DRG
DRG DRG DRG DRG
DRG

MDC 19 MDC 20 MDC 21 MDC 22 MDC 23 MDC 24 MDC 25

OUTPATIENT
DRG DRG DRG DRG DRG
DRG DRG DRG
DRG DRG DRG DRG DRG
DRG DRG DRG DRG DRG DRG DRG DRG DRG
DRG DRG DRG DRG DRG
DRG DRG DRG DRG DRG DRG DRG
DRG DRG DRG
DRG
DRG DRG
DRG
17
18
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 MDC 02: Diseases and Disorder of the Eye

DRG base: 01 Intraorbital procedures

02 Extraocular procedures except orbit
03 Intraocular procedures
04 Acute major eye infections
05 Neurological Eye disorders
06 Other disorders of the eye
MDC 02 Diseases and Disorder of the Eye

02 03 1 Intraocular procedures (W/O CC)

02 03 2 Intraocular procedures (W CC)
02 03 3 Intraocular procedures (W MCC)
02 04 1 Acute major eye infections (W/O CC)
02 04 2 Acute major eye infections (W CC)
02 04 3 Acute major eye infections (W MCC)
02 05 1 Neurological Eye disorders (W/O CC)
02 05 2 Neurological Eye disorders (W CC)
02 05 3 Neurological Eye disorders (W MCC)
 Ma
nua R
l EM
CODING
CODING
CLINICAL
CLINICALDATA
DATA E
CASE INPUT TOOL TWAR
TOOL
CASENOTE
NOTE INPUT F

(procedure, diagnosis)
SO
(procedure, diagnosis)
DRG
DRG GROUPER
GROUPER ARE
DEMOGRAPHIC W
DEMOGRAPHIC FT
&&ENCOUNTER SO
MIS ENCOUNTER
PATIENT MIS DATA
DATAINPUT
INPUT
(e.g. ID, age, sex, LOS, DoA,
(e.g. ID, age, sex, LOS, DoA,
DoD etc)
DoD etc)

UUTT P UUTT
P TP
TP
OOUUTFINANCIAL OOUUT
COSTING DIAGNOSIS
DIAGNOSISRELATED
RELATED
COSTING
REIMBURSEMENT MODULE E GROUPS
GROUPS(DRG)
(DRG)
MODULE WAR
FT
SO

EIA/BI RE COSTING
EIA/BI WA COSTINGDATA
DATA
OFT INPUT
S INPUT
22
Demograhic Admission
AdmissionRoom/
Demograhicdata
data Ward
Room/
capture
capture Wardclerical
clericalstaff
staff
Capture
Capture CSF
MO/HO
MO/HO
diagnosis(s)
diagnosis(s)
Capture
Capture
CSF
MO/HO/Paramedics
MO/HO/Paramedics
procedure(s)
procedure(s)
CSF
Verify
Verify Specialist/HoD
Specialist/HoD
diagnosis(es)
diagnosis(es)
Data
Dataentry,
entry,Coding
Codingofof
procedure(s) Clinical
ClinicalCoders
Coders
CSF

procedure(s)&&diagnosis(es)
diagnosis(es)
Verify
Verifydiagnosis(es)
diagnosis(es)&&
procedure(s) MRO
procedure(s)codes
codes MRO

Generate
GenerateHospital
HospitalDRG
DRG MRO,
MRO,Finance
Finance&&ITO
CSF
ITO
&&Prepare
PrepareReports
Reports
Evaluate
Evaluate&&verify
verifyreport
report Hosp
HospDirector,
Director,HoD,
HoD,
findings
findings MRO, Finance, ITO
MRO, Finance, ITO
Genarte
GenarteReport
Report (State) MRO
MRO(State)
(State) 23
(State)
24