Which statement about MS-DRGs is false?

Which statement about MS-DRGs is false?

• A. A patient claim may have multiple MS-DRGs.
• B. The MS-DRG payment may be lower than the actual service cost.
• C. Cost outlier payments can occur under special circumstances.
• D. Some hospitals are excluded from the Medicare inpatient PPS.

Answer: (A)

The statement that a patient claim may have multiple MS-DRGs is inaccurate. Each inpatient hospital claim is assigned a single MS-DRG based on the principal diagnosis and other factors such as procedures performed during the patient’s stay. This classification system is structured so that, although a patient might have multiple diagnoses or procedures that could potentially fit into different MS-DRG categories, only one is selected for billing purposes, typically the one that reflects the primary reason for admission or the most resource-intensive aspect of the patient’s care. The other statements regarding MS-DRGs reflect accurate aspects of the reimbursement system. For example, it is true that the MS-DRG payment might not cover the full cost of services provided, which can lead to financial challenges for hospitals. Additionally, there are provisions for cost outlier payments under certain conditions that aim to adequately compensate hospitals for exceptionally high-cost cases. Lastly, certain hospitals may be excluded from the Medicare inpatient prospective payment system (PPS), though this applies specifically to distinct categories of facilities and situations. Understanding that each claim is categorized into a single MS-DRG helps clarify the purpose of this classification in determining hospital reimbursement under Medicare.

The statement that a patient claim may have multiple MS-DRGs is inaccurate. Each inpatient hospital claim is assigned a single MS-DRG based on the principal diagnosis and other factors such as procedures performed during the patient’s stay. This classification system is structured so that, although a patient might have multiple diagnoses or procedures that could potentially fit into different MS-DRG categories, only one is selected for billing purposes, typically the one that reflects the primary reason for admission or the most resource-intensive aspect of the patient’s care.

The other statements regarding MS-DRGs reflect accurate aspects of the reimbursement system. For example, it is true that the MS-DRG payment might not cover the full cost of services provided, which can lead to financial challenges for hospitals. Additionally, there are provisions for cost outlier payments under certain conditions that aim to adequately compensate hospitals for exceptionally high-cost cases. Lastly, certain hospitals may be excluded from the Medicare inpatient prospective payment system (PPS), though this applies specifically to distinct categories of facilities and situations.

Understanding that each claim is categorized into a single MS-DRG helps clarify the purpose of this classification in determining hospital reimbursement under Medicare.