ReturnToWorkSA – Public hospital fee schedule 2016-17 3
ReturnToWorkSA – Public hospital fee schedule 2016-17 3
The 2016-17 Public hospital fee schedule is now available on our website and is effective 1 September 2016.
Inpatient (DRG) services
Inpatient services in public hospitals are billed using the casemix system known as Australian Diagnosis Related Groups (AR-DRG), commonly referred to as the ‘DRG’ system.
DRGs are based on International Classification of Diseases (ICD) codes and the extent of treatment that condition usually requires e.g. surgery, patients’ age, sex, presence of significant comorbidities or complications and the classification of the hospital. This and other relevant criteria are used to determine the cost of each episode of care.
Public hospitals treat compensable patients as either public or private patients:
1. Public patients are treated by doctors employed by the hospital and are billed under the DRG item numbers. The fee includes all costs relating to treatment, procedures, accommodation, theatre fees etc.
2. Private patients nominate their own private treating doctor. The hospital bills the patient for the accommodation, theatre, nursing costs etc, using the DRG item numbers and the patient’s doctor bills separately for the treatment or procedure using Medicare item numbers. Consequently, invoices for private patients are usually lower than those for public patients.
In most instances, patients injured at work are treated as private patients.
Changes to Diagnostic Related Groups (DRGs)
Up to 31 August 2016, ‘D’ was used to prefix each public hospital DRG item number. This was for keying purposes to distinguish the DRG item numbers from the Private hospital DRGs.
In the public hospital fee schedule, there were 2 fees for the 1 item (public and private patient fees) therefore, the highest fee was reflected in our system for the public hospital DRGs. This practice will change as of 1 September 2016.
Effective 1 September 2016, the ‘D’ will be replaced by two new prefixes for DRG item numbers and will reflect both public and private patient fees for the 1 item. For example when keying invoices:
For public patients – add the letter U to the DRG item number (e.g. UB03B)
For private patients – add the letter R to the DRG item number (e.g. RB03B)
An example of two fees for the one DRG item number that can now be recorded.
Item no / Description / Price x cost weight / Max feeUB03B / Spinal Procedures, Intermediate Complexity
(public patient) / $5,161 x 3.752 / $19,364.00
RB03B / Spinal Procedures, Intermediate Complexity
(private patient) / $5,161 x 2.044 / $10,549.00
This change has been implemented to more accurately reflect the correct fee in our system and limit the potential risk of over payments.
To ensure future invoices are processed accurately, please check the fee on the attached calculator prior to processing.
The version of DRGs being used was version 7.0 (up to 31/8/2016) and is now version 8.0 as of 01/09/2016.
Other services
For invoice processing purposes, all emergency department, outpatient and outreach services will remain the same. For example, the highest fee for each service is recorded in our system as there can be up to 10 fees for the one service therefore, it is important to check the fee on the calculator prior to processing the invoice.
If you have any questions, please contact us: Jenny 8233 2452 or Sonja 8233 2056.
ReturnToWorkSA – Public hospital fee schedule 2016-17 3