One part of the PEPPER report may not be reliable, says Deborah K. Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, a consulting company based in Shawnee, OK.
The concern is over the data relating to whether the hospital is frequently reporting just one secondary diagnosis that is considered a complication or comorbidity (CC), or major complication or comorbidity (MCC).
“That was what hospitals focused on in early days of DRGs because they got more money if they focused on assigning a case to the higher paying DRG with a complication or comorbidity, so they worked to find at least one CC because that amount of payment increase is significant,” Hale says. “But as we move more into value-based purchasing, we know it’s extremely important that we capture every condition that is reportable and supported by the record, so that we get credit for severity of illness for the risk adjustment process.”
The explanation in the PEPPER report indicates that being in the 80th percentile means you have many cases with only one CC or MCC, which could suggest errors related to overcoding of unsubstantiated diagnoses. Cases with a single CC/MCC are at greater risk of review to potentially lower the DRG by disallowing the single condition that increased the DRG payment, Hale explains. However, the PEPPER report suggests that being in the 20th percentile could indicate that you are underreporting CC or MCC conditions.
In fact, the formula does not consider the volume of DRGs without CC or MCC, Hale says.
“For those in the 20th percentile for single CC or MCC, we believe a more accurate description would be that among cases with CC or MCC, the hospital has a greater percentage of those with multiple CC or MCC diagnoses,” she says. “Therefore, rating at or below the 20th percentile in this measure could indicate the hospital is doing a good job of reporting all of the patient’s significant conditions as they strive to achieve credit for risk adjustment.”
The suggested audit intervention for this low outlier could send the hospital looking in the wrong direction for improvement opportunities, Hale explains.
One part of the PEPPER report may not be reliable, says Deborah K. Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, a consulting company based in Shawnee, OK.
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