N.J. Admin. Code § 10:52-7.1

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:52-7.1 - Diagnosis Related Groups (DRG)

(a) Diagnosis Related Groups (DRG) represent categories of hospital inpatients with similar clinical characteristics and, except for outliers, patients in each DRG can be expected to consume similar amounts of hospital resources. Assignment of a patient to a DRG requires the following information:

1. Principal diagnosis;

2. Secondary diagnosis;

3. Principal and other procedures;

4. Age;

5. Sex;

6. Discharge status; and

7. Birthweight (neonate): A newborn under 29 days of age.

(b) The appropriate classifications are reported here and these are the only classifications allowable for DRG assignment.

1. Principal diagnosis: The condition established after study shall be chiefly responsible for occasioning the admission of a patient to the hospital for care. The principal diagnosis must be coded using the International Classification of Diseases, 10th Revision, with Clinical Modifications (ICD-10-CM).

2. Secondary diagnosis: Conditions that exist at the time of admission or develop subsequently which affect the treatment received and/or the length of stay. Diagnoses which have no bearing on the treatment received during a current hospital stay are not appropriate for use in DRG assignment. All secondary diagnoses must be coded using ICD-10-CM.

3. Principal and other procedures: Diagnostic and therapeutic procedures performed during a patient stay. All procedures must be coded using ICD- 10-CM.

4. Age: Patient's chronological age at admission in years.

5. Sex: Patient's sex as male or female.

6. Discharge Status: The circumstances under which a patient left the hospital, coded as routine discharge to home, discharged against medical advice, transferred or died.

7. Birthweight: A newborn's weight in grams at birth.

8. Neonate: A newborn under 29 days of age.

(c) Admission: Patient hospitalized for a condition related to a recent spell of illness.

1. Patients who are treated and subsequently admitted through the emergency room shall be considered admitted to the hospital at the time the physician orders the admission. The cause of the admission shall be considered the cause of the emergency room treatment. Therefore, the course of treatment shall be considered one admission. Services rendered in the emergency room shall be reflected in the inpatient record and UB-92 claim form.

2. Similarly, a patient admitted for a course of treatment as a Same Day Surgery (SDS) patient, who subsequently is admitted from that mode of treatment shall be considered one admission. Services rendered in the SDS mode shall be reflected in the inpatient record and UB-92 claim form.

3. Readmissions are patients admitted to an acute care hospital at another time during the last seven days.

N.J. Admin. Code § 10:52-7.1

Amended by 50 N.J.R. 1261(a), effective 5/21/2018