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DRG Outlier Approved Payment Amount

CLM_INSTNL_DRG_OUTLIER_AMT

ON AN INSTITUTIONAL CLAIM, THE ADDITIONAL PAYMENT AMOUNT APPROVED BY THE PEER REVIEW ORGANIZATION DUE TO AN OUTLIER SITUATION FOR A BENEFICIARYS STAY UNDER THE PROSPECTIVE PAYMENT SYSTEM, WHICH HAS BEEN CLASSIFIED INTO A SPECIFIC DIAGNOSIS RELATED GROUP. [NCH]

Field Metadata

FHIR Resource
ExplanationOfBenefit
FHIRPath 
ExplanationOfBenefit.adjudication.where(
  category.coding.where(
    system = 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and
      code = 'CLM_INSTNL_DRG_OUTLIER_AMT'
  ).exists()
).amount.value
Coverage / Claim Type
  • Inpatient
  • SNF
Source View
V2_MDCR_CLM_INSTNL
Source Column
CLM_INSTNL_DRG_OUTLIER_AMT
Sources
  • FISS
  • NCH
Profiles
  • CMS

Example 

15.89

Mappings

CCW
  • NCH_DRG_OUTLIER_APRVD_PMT_AMT

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