DRG Revenue Calculation

In this page you’ll have a simple revenue calculation for the resulted DRG based on actual LOS and actual cost of the patient, current price of DRG equivalence point and the outlier limits for the DRG. Pricing is done for the DRG group that is active, the latest result, on the DRG grouping page.

Using weight tables

You can select DRG weight table for active DRG version. Each weight table has one or more stored base rates and daily rates for LOS outliers. If there are several base rates, the user interface displays a menu from which the base rate can be changed. You can also set the base rates yourself. You can restore the default value of each price with the button next to the field.

DRG revenue model

There are two simple pricing models available in VisualDRG: the one commonly used in Finland (Outlier cost thereshold and actual cost if outlier) and the one commonly used in Sweden (Outlier day and/or outlier cost thresholds). The system's country-specific settings determine which template is used, and the selection cannot be changed in the user interface.

The Swedish DRG revenue model works as follows. Please note that your actual DRG revenue calculation and reimbursement may differ from this.

  • If actual cost and actual LOS are both inside the outlier limits then DRG revenue = DRG weight x point price.
  • If actual cost is greater than outlier limit then DRG revenue = DRG weight x point price + actual cost exceeding the outlier limit.
  • If actual LOS is greater than outlier limit then DRG revenue = DRG weight x point price + daily rate x outlier days.
  • You may have outlier limits defined for both cost and LOS and they may include or exclude lower limits.

If the Finnish model is chosen, the LOS limits will be completely ignored and cost limit crossings are invoiced according to actual costs.

The following table describes the DRG revenue calculation results:

Field Description
DRG weight This field contains the relative DRG weight for the resulting DRG derived from the active DRG weight table. Relative weight measures the relative average actual cost. Weight 1,0 stands for an average patient what comes to expenses and weight 1,500 means a 50% more expensive patient cases on the average based on the selected weight table.
LOS limits Min – Max (days)

Some DRG weight tables or DRG revenue systems may include limiting values for the actual length of stay of the patient. If the length of stay is less than the lower limit specified or greater than the upper limit specified the case is interpreted as a DRG outlier case and charged based on actual cost. Depending on Your DRG weight table you may have either LOS limits or cost limits with either just upper limits or they may include both upper and lower limits.
Cost limits Min – Max (money)

Outlier limits for the actual cost of the patient cases interpreted in the same way as LOS limits.
Revenue Revenue is calculated by DRG weight and cost limits.

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