Administrative Memos

200209

FROM: Theodore O. Will, Chief Executive Officer
DATE: Aug 15, 2002
SUBJECT: Drg 475 (Respiratory System Diagnosis With Ventilator Support) Aggregate Data Remeasurement Report
IPRO CONTACTS:

Kathy Terry, Ph.D., Sr. Director, Data Analysis & Evaluation, Medicare/Federal Health Care Assessment, Ext. 261
Renato Estrella, RHIA, Administrator, HIM, Ext. 261

Enclosed please find a copy of IPRO's DRG 475 Aggregate Data Remeasurement Report. Although there has been a slight reduction in the payment error rate from 20% at baseline to 17% at remeasurement, this reduction is not statistically significant.

This DRG was originally selected by IPRO as a payment error prevention project because the Office of the Inspector General (OIG) lists DRG 475 as a DRG at great risk of upcoding. Moreover, IPRO analysis showed that the volume of Medicare claims billed to DRG 475 ranked it among the top 25 DRGs in the baseline 1998 New York State (NYS) Medicare claims data. DRG 475 continues to rank among the top 25 DRGs for NYS. Furthermore, according to both 1997 and 1998 MEDPAR data, when comparing DRG "pairs", the national "benchmark" billing proportion for DRG 475 was 13.2% vs. 86.8% for DRG 127 (Heart Failure and Shock). Analysis of 1997 NYS Medicare claims data revealed a proportion of 14.5% for DRG 475 when paired with DRG 127. Subsequent analysis of 1998 NYS Medicare claims data revealed a proportion of 15.0% for DRG 475, indicating higher proportions than the national "benchmark" for each of these years.

For both the baseline and remeasurement, a stratified random sample of approximately 25 records was selected from each of the 40 targeted hospitals. Remeasurement claims were selected from Medicare discharges between May 2001 and May 2002. It is significant to note that 17% of the cases reviewed in the remeasurement sample were found to be in error. Coding errors resulting in incorrect DRG assignments were identified in 16% of the cases. One percent (1%) of the cases were technically denied due to hospital failure to submit the requested medical records to IPRO for review. In comparison, the baseline error rate was 20% with 17% of the errors attributed to coding/DRG changes and 3% attributed to technical denials. Case specific findings for all denied cases have been previously sent under separate cover, however a hospital-specific case list has been included with the enclosed report if cases from your hospital were included in our study.

In addition to the DRG 475 Baseline Data Report disseminated by IPRO in February 2000, regional training sessions on coding guidelines for DRG 475 were provided across the state. All hospitals were invited to participate. We also prepared a DRG 475 educational training program for hospital information management personnel that offers 3.0 continuing education (CE) credits. This program is available on IPRO's website (www.ipro.org).

The aggregate project report is included as Attachment I. Attachment II provides hospital specific data along with a case list of all denied cases for your hospital if your hospital was selected for this project.

As a result of our remeasurement findings, IPRO recommends that all hospitals:

Conduct ongoing internal auditing and monitoring to ensure:

accurate coding and billing, and
complete medical record documentation.

Verify that your current coding and billing processes include:

continuing education sessions with coders on ICD-9-CM guidelines in the following areas:

Respiratory failure as a principal diagnosis
Sequencing of respiratory failure diagnoses
Assignment and duration of mechanical ventilation usage.

Provide physician education on appropriate medical record documentation to substantiate assignment of ICD-9-CM codes.
Incorporate a physician query process for answering documentation questions from the coding staff.
Include the results of this report, as well as hospital actions taken subsequent to its findings, into your hospital's corporate compliance plan. Targeted hospitals that have a high number of denials and/or high error rates compared to the baseline sample will be receiving a separate letter discussing our requirements for submitting a corrective action plan.

Please be reminded that final project results are shared with the Office of the Inspector General, as required.

Should you have any questions in regard to this report, please feel free to contact Dr. Kathy Terry (Data and Report Questions), extension 261 or Renato Estrella (Coding/DRG issues), extension 261.