Substance Use Disorder Rehabilitation Facilities (SUDRF) Billing
Inpatient residential Substance Use Disorder Rehabilitation Facilities (SUDRF) claims are subject to the Diagnosis Related Group (DRG)-based payment system. A ‘grouper’ program is used to assign each hospital discharge to an appropriately assigned single DRG based on essential data from the claim submission. The DRG assignment categorizes patients with respect to diagnosis, treatment and length of stay.
You must include the following key data items on the claim submission form, as applicable, to ensure accurate DRG grouping and payment:
- Revenue code (011X, 012X,013X,014X,015X)/HCPCS code
- Principal diagnosis
- Secondary diagnosis
- ICD-10 PCS (FL 74 on UB-04 form if billing for detox/rehab services). Note: Not providing information in this field may negatively impact grouping to the appropriate DRG and reimbursement.
- Comorbidities and complications
- Patient’s age and sex
- Discharge status
Samples of related SUDRF DRGs:
(reference TRICARE Reimbursement Manual, Chapter 6, Addendum C for complete DRG listing)
| DRG |
DRG Description |
|---|
| 894 |
Alcoholic/drug abuse or dependence, left against medical advice (AMA) |
| 895 |
Alcoholic/drug abuse or dependence with rehabilitation therapy |
| 896 |
Alcoholic/drug abuse or dependence without rehabilitation therapy with major complication or comorbidity (MCC) |
| 898 |
Alcoholic/drug abuse or dependence without rehabilitation therapy age 22 and older without major complication or comorbidity (MCC) |
| 899 |
Alcoholic/drug abuse or dependence without rehabilitation therapy ages 21 and younger without major complication or comorbidity (MCC) |
