Effective for dates of discharge on or after September 1, 2020, Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program will revert to Grouper version 36 of the All Patient Refined-Diagnosis Related Groups (APR-DRG) to process inpatient claims.
The Texas Health and Human Services Commission (HHSC) discovered lower reimbursements to hospital providers because of changes made in the grouping logic of Grouper versions 37 and 37.1 that were not recognized at the time of implementation.
Inpatient claims with discharge dates on or after September 1, 2020, which were originally processed under APR-DRG Grouper version 37.1, will be reprocessed using Grouper version 36 logic and relative weights.
HHSC is also reviewing claims with discharge dates between October 1, 2019, and August 31, 2020, that were processed under APR-DRG Grouper version 37 and 37.1. The impacted claims will be identified and reprocessed upon completion of the review.
For the information of hospitals that license 3M's Texas-specific reimbursement calculation software, 3M released a software update November 19, 2020, to reflect the above decision. Use of this software is a hospital decision and not required by HHSC.
Note: HHSC is currently reviewing processes to analyze the fiscal impact of annual APR-DRG version logic changes. Relative weights will be re-calibrated, if necessary, before each version implementation. TMHP will publish updated information as it becomes available.
For more information, call the TMHP Contact Center at 1-800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413.