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Classification Workshop Classification and Coding Standards #ABF15 27 May 2015 Learning Objectives The purpose of this workshop is to: • learn about the Activity Based Funding (ABF) classifications and the classification work program through interactive activities • enhance understanding of some of the variances which exist within the classification data, what impact these have and quality improvement strategies • enhance understanding of the use of classification data and systems beyond ABF purposes Session Outline • Welcome and introduction to the Independent Hospital Pricing Authority (IHPA) • Three workshops/tables to discuss different topics ‒ care types and classifications ‒ diagnosis and classifications ‒ use of classification systems beyond ABF • IHPA representative to sit on each table to facilitate discussion • 40 minute for each workshop before rotating topics • 30 minute question and answer session at the conclusion of the workshop IHPA and ABF • IHPA was established in December 2011 as part of the implementation of the National Health Reform Agreement (NHRA) • IHPA’s primary role is to determine the national efficient price (NEP) and national efficient cost (NEC) for public hospital services • NEP is a major determinant of the level of Commonwealth Government funding for public hospital services • Provides a price signal or benchmark for the efficient cost of providing public hospital services • NEC is for services that are not suitable for ABF, such as small rural hospitals which are block funded IHPA and ABF • IHPA has a number of other functions specified in legislation, for example: ‒ determining adjustments to the NEP to reflect legitimate and unavoidable variations in the cost of delivering health services ‒ determining data requirements ‒ developing and specifying the classifications for services provided by public hospitals The current ABF classifications • Admitted acute care – ICD-10-AM / ACHI / ACS with Australian Refined Diagnosis Related Groups (AR-DRGs) • Emergency care – Urgency Related Groups (URGs) and Urgency Disposition Groups (UDGs) – new classification in development • Non-admitted care – Tier 2 Non-Admitted Services – new classification in development • Admitted subacute and non-acute care – Australian National Subacute and Non-acute patient (AN-SNAP) classification • Mental health care – ICD-10-AM / ACHI / ACS with AR-DRG and URGs/UDGs – new classification in development • Teaching, training and research – new classification in development Care Types and Classifications Classification and Coding Standards #ABF15 27 May 2015 What is a care type • Care type refers to the nature of treatment provided to a patient during an episode of care • The overall nature of a clinical service provided to an admitted patient during an episode of care (admitted care), or the type of service provided by the hospital for boarders or posthumous organ retrieval (care other than admitted care) (Hospital service—care type, code N[N]. METeOR ID: 584408) • Care types for admitted care: – Acute care – Rehabilitation care – Palliative care – Geriatric evaluation and management – Psychogeriatric care – Maintenance care (non-acute) – Newborn care – Mental Health care Why are care types important? • Care types allow the identification of different types of care and services provided within a hospital or health service • The allocation of a care type in turn determines which casemix classification is used to classify the episode of care • The care type and associated casemix classification determines the amount of funding for an episode in an Activity Based Funding environment • Each care type has an associated data collection requirement Business rules for assigning care types • The care type is assigned by the clinician responsible for the management of the care, based on clinical judgement as to the primary clinical purpose of the care to be provided • For some care types there is a requirement for care to be managed by a clinician with specialised expertise • For some care types, there is a requirement that care is evidenced in the medical record via documentation such as multidisciplinary management plans or patient assessments • Evidence of care type change (including the date of handover, if applicable) should be clearly documented in the patient’s medical record • Other rules ‒ Retrospective care type changes ‒ Multiple care type changes within a 24 hour period ‒ Care type changes for same day interventions Difference in care type assignment across the country Jurisdiction A Jurisdiction B Jurisdiction C Jurisdiction D Jurisdiction E Jurisdiction F Jurisdiction G Jurisdiction H 93% 94% 95% 96% 97% 98% 99% Acute Care Rehabilitation Care Palliative Care Geriatric evaluation and management Psychogeriatric Care Maintenance Care 100% Acute care Acute care is care in which the primary clinical purpose or treatment goal is to: • manage labour (obstetric) • cure illness or provide definitive treatment of injury • perform surgery • relieve symptoms of illness or injury (excluding palliative care) • reduce severity of an illness or injury • protect against exacerbation and/or complication of an illness and/or injury which could threaten life or normal function • perform diagnostic or therapeutic procedures. Acute care excludes care which meets the definition of mental health care. Rehabilitation care Rehabilitation care is care in which the primary clinical purpose or treatment goal is improvement in the functioning of a patient with an impairment, activity limitation or participation restriction due to a health condition. The patient will be capable of actively participating. Rehabilitation care is always: • delivered under the management of or informed by a clinician with specialised expertise in rehabilitation, and • evidenced by an individualised multidisciplinary management plan, which is documented in the patient’s medical record, that includes negotiated goals within specified time frames and formal assessment of functional ability. Rehabilitation care excludes care which meets the definition of mental health care. Palliative care Palliative care is care in which the primary clinical purpose or treatment goal is optimisation of the quality of life of a patient with an active and advanced life-limiting illness. The patient will have complex physical, psychosocial and/or spiritual needs. Palliative care is always: • delivered under the management of or informed by a clinician with specialised expertise in palliative care, and • evidenced by an individualised multidisciplinary assessment and management plan, which is documented in the patient’s medical record, that covers the physical, psychological, emotional, social and spiritual needs of the patient and negotiated goals. Palliative care excludes care which meets the definition of mental health care. Geriatric Evaluation and Management (GEM) GEM is care in which the primary clinical purpose or treatment goal is improvement in the functioning of a patient with multi-dimensional needs associated with medical conditions related to ageing, such as tendency to fall, incontinence, reduced mobility and cognitive impairment. The patient may also have complex psychosocial problems. GEM is always: • delivered under the management of or informed by a clinician with specialised expertise in geriatric evaluation and management, and • evidenced by an individualised multidisciplinary management plan, which is documented in the patient’s medical record that covers the physical, psychological, emotional and social needs of the patient and includes negotiated goals within indicative time frames and formal assessment of functional ability. GEM care excludes care which meets the definition of mental health care. Psychogeriatric care Psychogeriatric care is care in which the primary clinical purpose or treatment goal is improvement in the functional status, behaviour and/or quality of life for an older patient with significant psychiatric or behavioural disturbance, caused by mental illness, an agerelated organic brain impairment or a physical condition. Psychogeriatric care is always: • delivered under the management of or informed by a clinician with specialised expertise in psychogeriatric care, and • evidenced by an individualised multidisciplinary management plan, which is documented in the patient’s medical record, that covers the physical, psychological, emotional and social needs of the patient and includes negotiated goals within indicative time frames and documented through formal assessment of functional ability. • Psychogeriatric care is not applicable if the primary focus of care is acute symptom control. Psychogeriatric care excludes care which meets the definition of mental health care. Maintenance (non-acute) care Non-acute care (maintenance) is care in which the primary clinical purpose or treatment goal is support for a patient with impairment, activity limitation or participation restriction due to a health condition. Following assessment or treatment the patient does not require further complex assessment or stabilisation. Patients with a care type of maintenance care often require care over an indefinite period. Maintenance care excludes care which meets the definition of mental health care. Newborn care Newborn care is initiated when the patient is born in hospital or is nine days old or less at the time of admission. Newborn care continues until the care type changes or the patient is separated: • patients who turn 10 days of age and do not require clinical care are separated and, if they remain in the hospital, are designated as boarders • patients who turn 10 days of age and require clinical care continue in a newborn episode of care until separated • patients aged less than 10 days and not admitted at birth (for example, transferred from another hospital) are admitted with a newborn care type • patients aged greater than 9 days not previously admitted (for example, transferred from another hospital) are either boarders or admitted with an acute care type • within a newborn episode of care, until the baby turns 10 days of age, each day is either a qualified or unqualified day • a newborn is qualified when it meets at least one of the criteria detailed in the newborn qualification status glossary item in METeOR. Within a newborn episode of care, each day after the baby turns 10 days of age is counted as a qualified patient day. Newborn qualified days are equivalent to acute days and may be denoted as such. Mental health care Mental health care is care in which the primary clinical purpose or treatment goal is improvement in the symptoms and/or psychosocial, environmental and physical functioning related to a patient’s mental disorder. Mental health care: • is delivered under the management of, or regularly informed by, a clinician with specialised expertise in mental health; • is evidenced by an individualised formal mental health assessment and the implementation of a documented mental health plan; and • may include significant psychosocial components, including family and carer support. Case study 1 A 55 year old male is admitted to hospital for treatment of medical complications due to the medication that he is taking for a diagnosed mental disorder. The patient is located on a general ward and their bedcard has a general medicine physician listed. Whilst admitted the patient is seen by their normal community mental health team as well as an inpatient mental health team for assessment. Case study 2 An 85 year old legally blind female with a history of well managed schizophrenia is admitted from her residential facility for treatment of transient ischaemic attacks (TIAs) and an ischaemic stroke. Since admission to the hospital the patient starts demonstrating paranoid psychotic behaviour that is associated with the TIAs and stroke rather than her mental illness. Once the patient has completed her medical treatment, the behaviour does not improve, resulting in the residential facility not being able to accept her back until her behaviour is under control. She is transferred to a specialist ward, and the psychogeriatric team assume responsibility for her care and develop a multidisciplinary plan to manage her behavioural symptoms. Case study 3 An 85 year old female has had an acute admission for a fractured humerus after tripping over in the street. The patient does not have any other comorbidities, and her regular medications consist of calcium and vitamin D supplements for the treatment of osteoporosis. During her acute admission she receives regular intervention by the physiotherapist. Once the patient is medically stable, her care is taken over by a rehabilitation team who undertake a functional assessment, develop and commence a multidisciplinary plan for a slow stream rehabilitation program. Case study 4 An 65 year old post-stroke patient is on a rehabilitation ward in an acute hospital whilst undertaking a rehabilitation program. They have been having an increasing number of epileptic episodes, which lead to a neurology team taking over care to investigate and further manage the patient’s epileptic episodes while the rehabilitation program is placed on hold. There are no beds elsewhere in the hospital, and so the patient stays on the rehabilitation ward. Case study 5 A 73 year old male is receiving rehabilitation after an extended acute hospital admission for a respiratory infection, however is still receiving dialysis twice a week for chronic renal failure. To receive the dialysis, the patient is transferred to the dialysis ward for the day, and then is transferred back to the rehabilitation unit. Case study 6 An 86 year old female, who lives at home alone has had a fall and fractured her left and right humerus. After a week the patient is deemed to be stable. The rehabilitation team review her and document that she will be accepted into a rehabilitation program once she has use (either partly or completely) of at least one of her arms. Her orthopaedic team anticipate that this may take up to three to four weeks. Case study 7 A 24 year old ventilator dependent male is a complete quadriplegic who was admitted to hospital for the treatment of a respiratory infection. During his admission he returns positive results for vancomycin resistant enterococci and methicillin-resistant staphylococcus aureus. The patient is stable, and is currently waiting placement in a suitable facility. Case study 8 A seven year old male is admitted to a paediatric hospital for treatment of Osteosarcoma which includes chemotherapy as well as surgery resulting in a below the knee amputation. Once the acute treatment is completed, the patient’s family and medical team decide that a period of rehabilitation is required for the patient to learn how to walk with his prosthesis. A paediatric rehabilitation team, in consultation with the medical team and the patient’s family, agree to take over his care, and develop a multidisciplinary rehabilitation plan which is documented in the patient’s medical notes. Diagnosis and Classifications Classification and Coding Standards #ABF15 27 May 2015 Diagnosis Patient diagnoses are one of the most valuable health data elements. Diagnostic information provides the basis for analysis of health service usage and clinical planning, epidemiological studies and monitoring of specific disease entities. The importance of diagnosis data in ABF will increase with diagnoses becoming a more integral part of classification systems built on capturing patient complexity and modelling across most care settings. How is diagnosis recorded / reported in Australia? International Statistical Classification of Diseases and Related Health Problems 10th Revision - Australian Modification (ICD-10-AM) • 6th edition, 7th edition, 8th edition and 9th edition • ICD-10-AM is a hierarchical classification of diseases and health related problems. Systematized Nomenclature of Medicine - Clinical Terms - Australian version Emergency Department Reference Set (SNOMED CT-AU EDRS) • SNOMED CT-AU is a clinical terminology which uses a structured vocabulary to describe the care and treatment of patients. • There is a subset for emergency department care ie the EDRS. Australian Rehabilitation Outcome Centre (AROC) impairment type • AROC impairment codes describe the primary type of patient impairment in a rehabilitation episode. How is diagnosis reported in each care setting Setting Emergency Admitted Acute Non-admitted Admitted Subacute Mental Health Diagnosis classification type used ICD-10-AM 6th – 9th edition ICD-10-AM 9th edition Not reported ICD-10-AM 9th edition ICD-10-AM 8th – 9th edition SNOMED-CT-AU EDRS ICD-9-CM 2nd edition AROC impairment type Application in ABF classification systems Emergency care – Urgency Related Groups (URG) • principal diagnosis is used in conjunction with other variables to assign presentations to URGs Admitted acute care – Australian Refined Diagnosis Related Groups (AR-DRG) • diagnosis is used in conjunction with procedures/interventions and coding standards to assign episodes to DRGs Admitted subacute and non-acute care – Australian National Subacute and Non-Acute Patient (AN-SNAP) • specific diagnoses are used in conjunction with other variables to assign episodes to AN-SNAP classes Mental health – Australian Mental Health Care Classification (AMHCC) (under development) • diagnosis has been identified as a cost driver; application in the classification system is under consideration Impact Poor quality diagnosis data impacts the ability to: • monitor and predict disease incidence and prevalence • plan and model clinical pathways and services eg creates an inaccurate representation of services required • accurately assess and model costs associated with disease prevalence, morbidity and mortality • classify diagnoses into homogenous groups eg decreases the predictive power of classifications. What does this mean and how does variation occur?... Impact – case example 1 Distribution of presentations to ED across Major Diagnostic Blocks (MDB). MDBs are 28 categories into which all possible principal diagnoses fall. The diagnoses in each category correspond to a single body system or aetiology, broadly reflecting the speciality providing care. MDBs are based on the Major Diagnostic Categories (MDCs) used in the Admitted Acute AR-DRG classification system. Impact – case example 1 cont. Figures reflect the percentage of total presentations reported by each jurisdiction. Jurisdictions MDB A B C D No diagnosis code reported 3.1 3.3 4.1 8.3 2B Injury, single site, major 17.9 15.8 11.9 15.4 2BA Injury, single site, minor 4.2 6.5 11.0 4.4 3C Digestive system illness 11.8 11.7 11.1 8.5 4 Psychiatric illness 2.9 3.4 2.4 2.1 6 Other presentation 5.4 10.3 6.0 7.4 Impact – case example 2 Variation in DRG complexity assignment: DRG complexity Jurisdiction A Jurisdiction B Jurisdiction C N % N % N % 50,922 13.3 30,262 13.0 15,486 10.9 A Highest consumption of resources B Second highest consumption of resources 132,091 34.4 92,086 39.6 46,747 33.0 C Third highest consumption of resources 30,053 7.8 16,547 7.1 14,192 10.0 D Fourth highest consumption of resources 6,809 1.8 1,209 0.5 756 0.5 Z No complexity split 164,248 42.8 92,374 39.7 64,552 45.5 384,123 100 232,475 100 141,733 100 Total Impact – case example 3 Clinical documentation and impact to DRG assignment: Discharge Summary – initial Presenting problem • Hemiplegia Principal diagnosis • Cerebral infarct Secondary diagnosis • Type 2 diabetes mellitus • Ex smoker • Mid stream urine: E.Coli • Na 125 mEg/L • Physiotherapy • Occupational therapy • B70B Stroke and other cerebrovascular disorders with severe CC Test results Interventions DRG Impact – case example 3 cont. Full story of the admission • A patient is admitted to hospital with right sided weakness and is subsequently diagnosed with cerebral infarct. • The patient has a history of type 2 diabetes mellitus and undergoes regular blood sugar level monitoring while in hospital. • The patient has residual hemiparesis following the stroke. • While in hospital the patient becomes feverish and confused, and receives antibiotics for an E.Coli urinary tract infection. The patient is also placed on fluid restriction for hyponatraemia. • The patient receives assessment from both physiotherapy and occupational therapy. • Following a period of stay in hospital, the patient is discharged to a rehabilitation facility. Impact – case example 3 cont. Clinical documentation and impact to DRG assignment: Discharge Summary – revised Presenting problem • Hemiplegia Principal diagnosis • Cerebral infarct Secondary diagnosis • Type 2 diabetes mellitus • Urinary tract infection • Hyponatraemia • Ex smoker • Mid stream urine: E.Coli • Na 125 mEg/L • Physiotherapy • Occupational therapy • B70A Stroke and other cerebrovascular disorders with catastrophic CC Test results Interventions DRG Recording to Output Capture / Recording Output Coding Reporting Causes of variation Factors affecting recording / reporting of diagnosis: • different terminology used by clinicians or in IT systems • clinical documentation recorded by clinicians • clinical practice eg what is identified as the principal diagnosis for a patient with multiple factors • collection practices eg use of coding staff in certain care settings and not others • different versions of diagnosis are currently used eg different classification type or different version within the same classification type • different code sets / pick lists used • different codes used to record the same condition • different capacity of IT systems eg some record principal and additional diagnoses where as some only record the principal diagnosis • policy and business rules Variation – case example 4 Collection and reporting of diagnosis across care settings: Setting Captured by Coded by Reported by: Emergency Admitted Acute Non-admitted Admitted Subacute Mental Health Clinician Clinician Clinician Clinician Clinician - Coding staff - Coding staff; sometimes not at all Coding staff; sometimes not at all Clinician / Clerical staff Coding staff - Clinician / Clerical Clinician / Clerical / Coding staff / Coding staff Variation – case example 5 Variation in diagnosis classification systems used to collect / report ED principal diagnosis: Diagnosis classification system Total number of episodes reported % of episodes ICD-10-AM, 7th edition 2,077,202 34.7% ICD-10-AM, 6th edition 1,953,620 32.7% ICD-10-AM, edition not specified 297,176 5.0% 1,424,693 23.8% 70,458 1.2% 142,224 2.4% 17,517 0.3% 5,982,890 100.0% SNOMED-CT-AU ICD-9-CM, 2nd edition Other system No diagnosis classification Total episodes Variation – case example 6 Variation in codes used by jurisdictions for presentations to ED with a diagnosis of pneumonia: Considerations: • 11 different codes used to report pneumonia. • Use of codes varies across jurisdictions. • Feedback from clinicians indicates that the identification of the type of bacterial organism would not occur during the ED stay unless it had been identified prior to presentation. • Clinical advice also indicated that it is necessary to identify viral pneumonia as distinct from bacterial or other types of pneumonia. Variation – case example 6 cont. Jurisdictions Code ICD-10-AM description A J129 Viral pneumonia unspecified 67 J13 Pneumonia dt Streptococcus pneumoniae J157 Pneumonia dt Mycoplasma pneumoniae J159 Bacterial pneumonia unspecified J160 Chlamydial pneumonia J168 Pneumonia dt oth spec infect organisms J180 Bronchopneumonia unspecified J181 Lobar pneumonia unspecified J182 Hypostatic pneumonia unspecified J188 Other pneumonia organism unspecified J189 Pneumonia unspecified B C D E F G H Total 271 488 57 40 23 946 645 92 58 40 1 836 4 102 21 13 449 1,209 1,235 30 140 32 3,096 141 0 161 538 504 1,571 213 622 1,144 10,079 1,401 10 2 1 3 27 1,732 4,756 65 151 13,462 0 198 195 365 2,254 423 1,754 5,189 15,553 896 217 708 11,391 28,765 Variation – case example 6 cont. 30,000 28,765 25,000 20,000 15,000 13,462 10,000 5,189 4,756 5,000 3,096 946 836 J129 J13 140 0 3 J160 J168 J157 J159 0 J180 Viral Bronchopneumonia Bacterial Lobar J181 J182 J188 J189 Other and unspecified Strategies for improvement – reflection Refer back to factors causing variation, and discuss potential strategies to improve the consistency and quality of diagnosis data. High “Quick Wins” “Major Projects” “Fill Ins” “Hard Slogs” Impact Low Low Effort High Improvement • focus on training and education of staff to document/record the correct code and/or information and create awareness of business rules and policy requirements • implement standard lists and terminology for diagnosis codes (including diagnosis classification version) • ensure only valid diagnoses are being used as a principal diagnosis eg not recording external cause codes as principal diagnoses • assess whether appropriate codes are implemented in IT systems; also the ease of use for clinicians eg clinically meaningful, burden of use, etc • ensure IT systems are able to record the required information eg principal and additional diagnoses • develop validation of diagnosis mechanisms eg data validation, coding practices, etc. Resources Australian Institute of Health and Welfare – Metadata Online Registry (METeOR) • Definitions of diagnosis data as per the different national minimum data sets and data set specifications • http://meteor.aihw.gov.au/ ICD-10-AM manuals and reference documents (including Australian Coding Standards) • http://ihpa.gov.au/internet/ihpa/publishing.nsf/Content/Classifications • https://www.accd.net.au/Icd10.aspx SNOMED-CT-AU • http://www.nehta.gov.au/our-work/clinical-terminology/snomed-clinical-terms Use of classification systems beyond Activity Based Funding Classification and Coding Standards #ABF15 27 May 2015 Emergency classification descriptions Urgency Disposition Groups (UDGs) Classify patient presentations to emergency services (levels 1, 2 and 3A) Variables: - Type of visit - Episode End Status - Triage category Urgency Related Groups (URGs) Classify patient presentations to emergency departments (levels 3B, 4, 5 and 6) Variables: - Type of visit - Episode End Status - Triage category - Major Diagnostic Blocks URG descriptions Type of Visit - The reason the patient presents to an emergency department: Episode End Status: The status of the patient at the end of the non-admitted patient emergency department service episode: Triage: The urgency of the patient's need for medical and nursing care as assessed at triage: Emergency presentation Admitted to hospital 1. Resuscitation: immediate (within seconds) Return visit, planned ED completed; not admitted/referred 2. Emergency: within 10 minutes Pre-arranged admission ED completed; transfer 3. Urgent: within 30 minutes Patient in transit Died in ED 4. Semi-urgent: within 60 minutes Dead on arrival Dead on arrival 5. Non-urgent: within 120 minute Major Diagnostic Block: category into which the patient's emergency department stay is grouped dependent on diagnosis: Diagnosis codes are reported using SNO-MED, ICD-10-AM or ICD-9-CM Case Study 1 Hospital ABF has conducted an audit and found that there is large cohort of patients that have a length of stay of between 4 – 48 hours. All of the patients initially present to the emergency department, however some are admitted, some stay in ED and some are transferred to other hospitals. How can the hospital use the Emergency care classification system to analyse this cohort of patients? The AN-SNAP V4 classification Subacute care comprises the following care types: • Rehabilitation care • Palliative care • Geriatric evaluation and management (GEM) care • Psychogeriatric care • Non-acute care The AN-SNAP classification has: • 130 classes for subacute and non-acute care • 89 for overnight admitted episodes/phases • 6 for same-day admissions • 35 for non-admitted episodes/phases. AN-SNAP Variables In the admitted branch, the variables used for grouping are: Care type • Characteristics of the patient and the goal of treatment Function (motor and cognition) on admission • All care types Phase (stage of illness) • Palliative care Impairment • Rehabilitation Behaviour • Psychogeriatric Diagnostic codes Age Length of stay (LOS) • Geriatric evaluation and management • Palliative care, rehabilitation, non-acute and to identify paediatric episode/phases • Psychogeriatric and non-acute Case Study 2 A health service is looking at the existing subacute services to determine future planning. In particular, paediatric rehabilitation and palliative care services. Anecdotally the health service has heard that paediatric patients are having their acute portion of the admitted episode in one health service, but are required to transfer to another health service for the purposes of admitted rehabilitation services. Additionally, there has been anecdotal evidence that some patients are unable to access existing speciality subacute services, and are in acute care hospitals on general wards. How could AN-SNAP be used to assist with service planning to accommodate these patients? Tier 2 Tier 2 categorises a hospital’s non-admitted services into classes which are generally based on the nature of the service provided and the type of clinician providing the service. Composed of four groups: 10 series Procedures 20 series Medical Consultation 30 series 40 series Diagnostic services Allied health and/or clinical nurse specialist intervention Case Study 3 A university is setting up a new postgraduate nursing degree that is focused on the non-admitted setting and providing case management. The university will be specifically looking at non-admitted services that are predominantly nursing led. How can the university use the Tier 2 classification to assist with planning this degree? AR-DRG ICD-10-AM diagnosis codes and ACHI procedure codes are used to assign an episode of care to an AR-DRG Some other factors may also be considered for certain AR-DRGs: Length of stay (LOS) Admission weight for neonates Mental legal status Case Study 4 A researcher is conducting a study that examines surgical interventions for older patients who fall. How can DRGs be used to assist in identifying this group of patients? Question and Answer