DRG Coding Advisor
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As a certified coding specialist (CCS), Deborah Hale regards the impact of proper documentation with the keen eye of an expert. Using that specialized experience, she and her team at Administrative Consultant Services Inc. in Shawnee, OK, have developed a unique approach to documentation improvement. "We have begun to tie documentation improvement into case management or performance improvement," she explains. "We start by using data to identify the hospital’s documentation improvement needs as they relate to clinical and financial outcomes."
Hale identifies these key steps in her process:
- Analyze your data to find out which diagnosis-related groups (DRGs) have the greatest opportunity for improvement in physician documentation.
- Review the records to confirm documentation needs.
- Present your findings and the proposed solution to the medical staff.
- Implement a concurrent process to prompt the physicians for the documentation needs you have identified.
"This can either be done by a concurrent coder reviewing the record to see if the terminology used is specific enough to code accurately or whether important documentation has been left out, or by using tools to prompt the physician," she notes. "It could be a sticker on the chart; it could be a form; or more effectively, it could be a very direct communication with that physician."
Most critical, of course, is obtaining physician buy-in. "Physicians need to know why they should pay more attention to coding," she says. "If they understand the motivation behind it, they react." This system works, Hale asserts, "because physicians are very data-driven; they care about report cards."
When physicians see that their cost, length of stay, and mortality rate are higher than would be expected for urinary tract infection, for example, their normal response is to say their patients are sicker, Hale notes. "Our response is, the documentation does not reflect that.’ When we show them our data, they realize that they are not documenting in a manner that will get them credit for the appropriate severity of illness for their patient. The coder may have actually coded correctly, but the doctor may not have used the right terminology."
Hale and her staff examine specific DRGs and compare those DRGs with their higher-weighted pair in state and national claims data. "We look at average length of stay, cost, and mortality rates for those DRGs so we can identify the DRGs in which we are most likely to be under-reporting severity of illness — and thus being underpaid as well — and focus on those DRGs," Hale explains.
If a hospital was assigning DRG 320 (urinary tract infection) much more frequently than 416 (septicemia), and its mortality rate was higher than expected, that would suggest the doctors were using terminology such as urosepsis (which codes to urinary tract infection alone) rather than the more accurate terminology, generalized septicemia (416), which merits a higher payment, she says. "So based upon that data, we would audit the 320 records to determine, if in fact, this low-weighted DRG was incorrectly assigned based on the clinical evidence in the record," she concludes.
In an effort to ensure more accurate coding, Administrative Consultant Services provides detailed query forms to prompt the physicians for complete and accurate information. These forms include clinical criteria for validating specific diagnoses and information on distinguishing between different diagnoses.
The consulting firm has an impressive track record. At one hospital, the case mix index increased from 1.7042 to 1.8400, resulting in a $2 million annual increase in DRG reimbursement. At another, the average Medicare length of stay was decreased from 7.1 days to 5.4 days, resulting in a cost savings of $750,000.
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