Administrative Memos

200207

FROM: Theodore O. Will, Chief Executive Officer
DATE: Jul 18, 2002
SUBJECT: DRG 416 (Septicemia, Age Greater than 17) - Aggregate Data Remeasurement 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 DRG 416 "Aggregate Data Remeasurement Report". This report describes our remeasurement findings and provides a comparison to the baseline error rate for our DRG 416 PEPP project. The baseline error rate was 27% ¹ with 22% of the errors attributed to coding/DRG changes, 4% attributed to technical denials, and one (1) admission denial. While remeasurement shows that hospitals have made improvements and reduced the payment error rate, it is still problematic at 19%.

This DRG was originally selected as a PEPP project because our analysis showed DRG 416 (Septicemia, Age Greater than 17) to be among the top twenty (20) DRGs billed in New York State (NYS) Medicare claims data. In addition, the Department of Health and Human Services, Office of the Inspector General (HHS/OIG) identified DRG 416 as a DRG at great risk for upcoding.

As in our baseline sample, a total of 400 cases were randomly selected for remeasurement from NYS Medicare claims billed to DRG 416. Remeasurement cases were selected from discharges which occurred between May 1 and August 31, 2001. It is significant to note that 19% were found to be in error. Specifically, coding errors resulting in incorrect DRG assignments were identified in 18% 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. Case specific findings for all denied cases have been previously sent to the hospital 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.

Earlier in this project, IPRO disseminated the "DRG 416 Aggregate Data Report" in March 2001. A hospital specific list of Medicare cases billed to DRG 416 in calendar year 2000 was provided at that time to assist hospitals in their assessment of DRG 416 coding/billing practices. We continue to encourage all Medicare Prospective Payment System (PPS) hospitals to conduct DRG 416 monitoring and auditing activities as part of their hospital compliance programs in order to ensure that coding is consistent with coding guidelines and accurately reflects the principal diagnosis based on physician documentation in the medical record. It is apparent that improvement efforts need to continue as indicated by the 18% error rate at remeasurement.

To assist hospitals in their improvement efforts, IPRO developed and disseminated DRG 416 educational materials on CD ROM for hospital coders and physicians on February 1, 2002 (PEPP Administrative Memorandum #2002-01). The program offers Continuing Medical Education (CME) credits for physicians and Continuing Education (CE) credits for hospital information management personnel. The programs are also available on IPRO's website at http://www.ipro.org.

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.

Reassigned DRG Code - Narrative Description and Weights

¹Several denied baseline cases were re-reviewed and resolved after the baseline report was released. Therefore, the error rates for the baseline sample included in this report are somewhat lower than the ones in the previous report.