What are Dyads and Triads within the DRG Reimbursement System?

In medical coding, Diagnosis-Related Groups (DRGs) are a reimbursements methodology that groups patients based on their similarity in relation to the consumption of resources required to provide their care. The determination of which DRG a patient’s admission falls into is based on the codes reported for their diagnoses and treatments, along with certain demographic factors such as age and gender. DRGs are used primarily for calculating reimbursement in the hospital inpatient setting, particularly under the Medicare Inpatient Prospective Payment System (IPPS) in the United States.  

Some DRGs are standalones called base DRGs, but in many cases base DRGs are subdivided, creating two or three DRGs, to allow for a more exact accounting of the severity of patient illness and resource utilization. 

In the DRG system, a dyad refers to a base DRG divided into a pair of DRGs that are related but differ in their reflection of severity and resource consumption based on the presence or absence of diagnoses that are considered complications or comorbidities (CCs), major complications or comorbidities (MCCs) or specific procedures. These pairs typically include: 

1. One DRG for cases with CC/MCC: This DRG is assigned when the patient's condition is more severe, involving significant complications or comorbidities that impact the complexity and cost of care. 
2. One DRG for cases without CC/MCC: This DRG is assigned when the patient's condition is less severe, because there are no significant complications or comorbidities. 

For example, if a patient is treated for heart transplant, the DRG system has two related DRGs: 

• DRG 001: Heart transplant or implant of heart assist system with MCC 

• DRG 002: Heart transplant or implant of heart assist system without MCC 

A triad in the DRG system refers to a set of three related DRGs that are stratified based on the severity of the patient's condition. These triads typically include: 

1. One DRG for cases with MCC: This DRG covers the most severe cases, those involving major complications or comorbidities that significantly increase the complexity and cost of care. 
2. One DRG for cases with CC: This DRG is for cases that involve complications or comorbidities that are significant but not as severe as those classified as MCCs. 
3. One DRG for cases without CC/MCC: The same as with dyads, this DRG is assigned to the lease severe cases as evidenced by the absence of CCs or MCCs. 

An example of a triad would be the DRGs related to wound debridement for injuries: 

• DRG 901: Wound debridements for injuries with MCC 

• DRG 902: Wound debridements for injuries with CC 

• DRG 903: Wound debridements for injuries without CC/MCC 

Understanding Dyads and Triads to Mitigate Financial Risk 

The specific DRGs within a dyad or triad generated by an individual hospital correspond to the severity of illness of their patient population. The DRG system ties severity to resource expenditure and is thereby also an indicator of anticipated reimbursement. As such, comparison of an organization’s DRG trends against that of their peers can provide insight into potential areas of financial risk. When an organization’s assignment of higher weighted DRGs within a dyad or triad falls below that of their peers, this may indicate an area of unrealized revenue. When assignment of higher weighted DRGs in a dyad or triad exceeds their peers’, there is a risk of overpayment. Regular benchmarking of DRG trends against peer data is essential to recognizing DRG selections whose accuracy could benefit from further scrutinization.  

There are many procedures, products and strategies an organization can use to ensure their DRG calculations accurately express how sick their patients are, and the costs related to caring for them.  

Accurate Documentation and Coding 

• Ensure Comprehensive Documentation: Accurate documentation of all diagnoses, procedures, and comorbidities is essential. Coders must be vigilant in identifying all conditions that could qualify a case for a higher-weight DRG, particularly within triads and dyads. For instance, missing a major complication or comorbidity (MCC) can result in assigning a lower-weighted DRG, leading to financial loss. 
• Thorough Review of Patient Records: Before finalizing a DRG, review the patient's entire medical record to ensure that all relevant information is captured. This includes looking for secondary diagnoses that could elevate the DRG from a lower to a higher tier within a triad or dyad.

• Regular Training for Coders: Coders should receive ongoing education on the latest DRG stratifications, including the nuances of triads and dyads. Understanding how complications and comorbidities affect DRG assignment is crucial for minimizing errors that could lead to underpayment. 
• Clinician Education: Educate physicians and other clinicians on the importance of detailed documentation. Often, the difference between one DRG and another within a triad or dyad comes down to how well clinical information is documented.

• Internal Audits: Regularly audit coding practices to ensure that DRG assignments are correct. Audits can help identify patterns of undercoding or overcoding, both of which can lead to financial risk. For example, consistent assignment of lower DRGs in a triad could indicate missed complications that should have been documented and/or coded. 

• External Audits: Consider periodic external audits to provide an objective review of your coding practices. These audits can identify potential areas for improvement and help ensure compliance with CMS guidelines. 

 Leveraging Coding Tools and Software

• DRG Coding Software: Utilize advanced coding software that not only integrates the latest DRG classifications but also includes analytics capabilities to track and compare your facility's triad and dyad DRG distribution against industry benchmarks and peer facilities. This allows for a deeper understanding of how your coding practices align with others and helps identify potential areas for improvement to optimize reimbursement. 
• Benchmarking Tools: Implement benchmarking tools that provide insights into DRG assignment trends across similar healthcare facilities. By comparing your triad and dyad distributions with those of other institutions, you can spot deviations, uncover potential financial risks, and make informed adjustments to your coding practices.

• Ensure Compliance with CMS Guidelines: Accurate DRG assignment is not only important for financial health but also for compliance. Misclassification can lead to audits, recoupments, or even penalties from CMS. Focusing on compliance will help avoid these costly outcomes. 
• Review Denials and Appeals: Monitor denied claims and the reasons for denial. Many denials occur due to incorrect DRG assignment. By understanding and addressing the root causes, you can reduce future denials and the associated financial losses.

• Identify High-Risk Patients Early: For patients with complex conditions or multiple comorbidities, ensure that their cases are flagged for careful review to capture all relevant diagnoses. This can prevent the assignment of a lower DRG when a higher one is warranted. 

• Enhance CDI Programs: Clinical documentation improvement programs should focus on identifying conditions that lead to the most appropriate DRG within a triad or dyad. By working closely with clinicians, CDI specialists can help ensure that documentation accurately reflects the severity of the patient’s condition. 

Effectively managing coding and CDI practices to ensure accurate assignment of an admission to a dyad or triad within the DRG system is crucial for optimizing hospital reimbursement and maintaining compliance. By ensuring accurate documentation, leveraging advanced coding tools, and regularly benchmarking your DRG assignments against industry standards, you can proactively mitigate financial risks. Continuous education and diligent auditing practices further strengthen your ability to capture the full complexity of patient cases, ensuring that your organization is compensated fairly, while adhering to regulatory guidelines. Through these strategies, you can enhance financial performance and uphold the integrity of the coding processes upon which reimbursement is founded.