Administrative Memos

200206

FROM: Theodore O. Will, Chief Executive Officer
DATE: Jul 05, 2002
SUBJECT: Top 7 DRGs - Aggregate Report
IPRO CONTACTS:

Kathy Terry, Ph.D., Sr. Director of Data Analysis & Evaluation, Medicare/Federal Health Care Assessment, Extension 261 and Renato Estrella, RHIA, Administrator, Health Information Management (HIM), Extension 261

Enclosed please find a copy of IPRO's TOP 7 DRGs Aggregate Data Report (Attachment I) For the purposes of this study, the top 7 DRGs were defined as those DRGs which represented the highest volume of New York State (NYS) Medicare Inpatient Prospective Payment System (PPS) claims for calendar year (CY) 1999. The overall coding error rate for these top DRGs was high at 15.6%. Although any case in error is cause for concern, the finding that the highest volume DRGs in NYS are so error-prone is especially challenging and problematic. The most obvious issue exists in the finding that medical records were billed without all of the documentation in the chart to support the assigned DRG. Some DRGs had much higher error rates than others (i.e., DRG 014 at 25%, DRG 089 at 37% and DRG 296 at 23%), these DRGs in particular should receive special attention to identify if they are error prone DRGs in your hospital. The Top 7 DRGs studied were:

DRG 014 - Specific Cerebrovascular Disorders Except Transient Ischemic Attack
DRG 088 - Chronic Obstructive Pulmonary Disease
DRG 089 - Simple Pneumonia and Pleurisy, Age >17 with CC
DRG 116 - Other Permanent Cardiac Pacemaker Implant or PTCA with Coronary Artery Stent Implant
DRG 127 - Heart Failure and Shock
DRG 209 - Major Joint and Limb Reattachment Procedures of Lower Extremity
DRG 296 - Nutritional and Miscellaneous Metabolic Disorders, Age >17 with CC

For each of the Top 7 DRGs, the top 10 providers were selected, as defined by the highest volume of claims billed for each of these DRGs for CY 1999. From the 10 providers, 35 cases with discharge dates between October 1, 1999 and March 31, 2000, were selected for validation and coding DRG assignment.

The error rates ranged from a low of 0% for DRG 209 to a high of 37.1% for DRG 089 ¹. However, not all hospitals had cases selected for review. If cases from your hospital were included in our study a hospital-specific report, including aggregate comparisons, is included as Attachment II along with a detailed case list (Attachment III) which identifies problematic cases. It should be noted that these cases underwent first level coding validation in order to abstract information necessary to justify the DRG assignment. The cases did not proceed through the entire case review process and therefore no fiscal adjustments were made.

The majority of DRG reassignments for the medical DRGs (014, 088, 089,127, and 296) were based on category of concern D03 (Principal diagnosis not principal reason for hospitalization). For the surgical DRG 116, the majority of DRG reassignments were based on category of concern D10 (Procedure billed, but not substantiated by record). There were no DRG reassignments for the surgical DRG 209. Hospitals may wish to prioritize and direct their educational efforts towards improving documentation surrounding these issues.

As a result of this project, IPRO suggests that hospitals implement the following actions:

Conduct ongoing internal auditing and monitoring to ensure the accuracy of DRG assignments and the completeness of documentation.
Provide continuing education sessions for coders on ICD-9-CM guidelines in the following areas:

Criteria for assignment of principal diagnosis:

Circumstances of admission
Diagnostic workup
Treatment provide

Accurate assignment of procedure codes
Appropriate coding of other diagnoses (e.g., complications and comorbidities)
Appropriate coding for:

CVA vs TIA
COPD vs Bronchitis
Pneumonia vs COPD vs Heart Failure and Shock
Heart Failure vs Chest Pain
Dehydration vs Gastroenteritis

Provide physician education on appropriate and timely medical record documentation and its relationship to coding and DRG assignment.
Assure complete and timely documentation of medical records such as discharge summary, history and physical, and operative procedure reports to support accurate assignment of codes and DRGs prior to submitting the claim.
Establish a code of conduct for coding processes. You may wish to use the AHIMA Code of Ethics and Standards of Ethical Coding as your guide.
Incorporate the above activities into your hospital's voluntary compliance plan.

Should you have any questions regarding this report, please feel free to contact Dr. Kathy Terry Sr. Director of Data Analysis & Evaluation (data/report questions), or Renato Estrella, Administrator, HIM (coding/DRG issues).

¹All coding and DRG assignments were validated by a member of IPRO's coding staff who are CCSs, RHIT or RHIAs.