The learner will: Explain how revenue codes and DRG/APC groupers are used to categorize hospital services for payment. Distinguish between inpatient DRG and outpatient APC payment methodologies and their respective coding implications. Evaluate claims and grouping outputs to identify incorrect payment assignments or compliance discrepancies. Apply DRG and APC grouping logic to real clinical encounter data to ensure accurate billing and reimbursement. Analyze payer remittance data to verify the accuracy of DRG payment assignments and resolve discrepancies. Develop training or reference materials to educate staff on DRG/APC grouping principles and revenue code usage.

Before beginning this unit, learners should have: Working knowledge of medical coding systems (ICD-10-CM, CPT, HCPCS). Understanding of charge capture and coding workflows. Completion of Unit 3.4: Modifier Usage and NCCI Edits or equivalent practical experience in healthcare coding or billing.

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This unit is designed for individuals seeking to strengthen their expertise in hospital reimbursement systems, coding accuracy, and payment grouping logic. It is ideal for: Inpatient and Outpatient Coders – who need to understand DRG and APC assignment logic. Revenue Integrity and Reimbursement Analysts – focused on optimizing claim payment accuracy and compliance. Billing and Claims Professionals – responsible for validating revenue codes and grouping outcomes. Compliance and Audit Specialists – monitoring DRG/APC accuracy to mitigate financial and regulatory risk. Healthcare Finance and HIM Students – developing foundational knowledge of hospital payment methodologies.