It's when you compare the CDI working DRG with the coder's final DRG. Here we do it on a monthly basis. It indicates that we have followed the patient's hospitalization closely and have not found any query opportunities or needed clarifications concurrently-so when the coder gets the chart his/her work can be expidited. A matching DRG in my mind indicates that the DRG has been optimized and the documentation is clear.
We don’t have a goal for a DRG match, although we do identify a "working DRG" and the match % is tracked. I would argue against setting a really high goal though. My primary argument if it was suggested by our leadership would be that it's an unfair expectation because we are not seeing the entire record when we are calculating a perspective DRG. A lot can change in the 24-48hrs between a review and discharge (how often are you expected to review records?). If you are not reviewing post-discharge as well as concurrent, it is unfair to judge you on the entire record when the final diagnoses may not even be identified in the reviewed notes. I do a decent amount of retrospective reviews and it's amazing how many records end up with a different final DRG then what was expected concurrently. Even ones I reviewed concurrently myself! Often the discharge summery clarifies underlying conditions, signs and symptoms, ruled-out diagnoses that were not previously identified in the progress notes. This is especially true of short admissions. We also don’t have weekend coverage, so it is possible that we may not review for 3 or even 4 days on some occasions and much can happen in that time period. This includes surgical procedures and such. Another issue I see retrospectively is simply "alternative coding". There are many cases where several coders may choose a different Pdx leading to a different DRG. Both may be "correct" coding, even if they are not the same. Coding is somewhat subjective and it is not uncommon for one coder to read a complex chart and believe the care was primarily directed a one dx, while another coder my think that two dx were equally treated and use an alternative (more highly weighted) DRG. I also just think it’s the wrong focus for CDI. I think setting such a high goal for a DRG match would actually direct the CDS to spend an extensive amount of time learning procedure coding, surgical hierarchies, and coding clinics that may not be necessary. This does nothing to actually ensure a complete record, which should be the goal of CDI. You say a matching DRG indicates an optimized DRG and clear documentation? I don’t see that. I routinely see matching DRG's for coders/CDI on retrospective charts where there were query opportunities that would improve the DRG or clarify documentation. However, the CDI did not see it (or did not choose to query) and therefore the documentation is not in the record for the coder and they may not see the opportunity. Just having a matching DRG doesn't really indicate anything to me besides efficient use of an encoder. Don’t get me wrong, I get annoyed when I see blatantly wrong DRG assignment by CDI that obviously was not updated during the admission or shows lack of basic coding knowledge, but I certainly don’t think a matching DRG indicates good effort as a CDS.
That’s my two cents....
Katy Good, RN, BSN, CCDS, CCS Clinical Documentation Program Coordinator AHIMA Approved ICD-10CM/PCS Trainer Flagstaff Medical Center Kathryn.Good@nahealth.com Cell: 928.814.9404
Our program is aligned under quality and we practice 100% reconciliation. I agree that a definition is needed: you may be referring to what your goal is for completing reconciliation on all reviewed cases or you may be referring to an accuracy/error rate.
We approach from the standpoint of how a new CDS can lessen their learning curve, diligent reconciliation is necessary to see where you may have gone wrong in your DRG assignment and yes...since the course of treatment is fluid...many variables can affect the final outcome; but if you don't examine the final outcome, you can never fully identify opportunities and improve your process. This commitment to process improvement methodology is how a CDS moves from a novice to an expert. If you focus on a goal of 100% reconciliation on all cases for even a few months, you will likely uncover many areas in which CDI can have impact and then develop a business case for program growth and development.
Moreover, the driving influence behind our team and our organization is accuracy and quality of care. An accurate patient bill, final closure to our data integrity and the excellent services we provide, is an important part of our overall vision to provide a "remarkable patient experience, in every dimension, every time". I would encourage any program out there to look outside the box of any perceived CDI role; today's healthcare environment demands flexibility and increasing expertise in all facets of the patient encounter.
I whole heartedly agree with Katy. We are housed under quality and our focus tends to emphasize SOI/ROM. We have a significant improvement rate on that count.
Donna Kent, RN, BSN, CCDS Manager, Clinical Documentation Integrity Program Clinical Quality and Accreditation Torrance Memorial Medical Center ph.:310 784-6884 fax:310 784-6899 donna.kent@tmmc.com
Abby, tell me more. Do your new CDS have to look at how each case is coded? At this hosp it may be a couple of weeks before its final coded and by that time, we have forgoten what we were thinking. Could you explain more of your process. Do you do concurrent coding? Thanks.
Absolutely...we have a policy and a workflow. My e-mail address is below. If you will send a personal e-mail with contact information; I will be happy to share. Anyone is welcome to reach out that may like to learn more.
I agree with most of Katy's reply. Our DRG Reconciliation (or Mismatches) are for educational purposes only - not punitive.
For the many reasons Katy mentioned it does not seem realistic to hold the CDS responsible for matching the Final Coded DRG.
That being said, I think it completely depends on the focus of the program. Our focus seems to be much like Abby's Dept. We want that record coded as far as it can be coded before the Coder gets the chart. The Coder should not have to "diagnose" what happened in that record. If we are doing our jobs as CDS then we should be clarifying that documentation as much as possible. And that means reviewing those cases concurrently and tweaking that documentation and coding.
Having been an Inpt. Line Coder in the past I hold myself at a higher standard when I'm reviewing my Mismatches. I probably question more of my "Mismatched" DRGs than my co-workers do - its a matter of professional integrity. When I review those charts on the floor I try to think to myself, "what documentation would I need as a Coder to code this chart when I get it in my queue?" "What do I need clarified?"
However, Im glad Im not held to a rate! (But you never know...)
Comments
Term I don't recall hearing before.
Thanks
Don
I do a decent amount of retrospective reviews and it's amazing how many records end up with a different final DRG then what was expected concurrently. Even ones I reviewed concurrently myself! Often the discharge summery clarifies underlying conditions, signs and symptoms, ruled-out diagnoses that were not previously identified in the progress notes. This is especially true of short admissions. We also don’t have weekend coverage, so it is possible that we may not review for 3 or even 4 days on some occasions and much can happen in that time period. This includes surgical procedures and such.
Another issue I see retrospectively is simply "alternative coding". There are many cases where several coders may choose a different Pdx leading to a different DRG. Both may be "correct" coding, even if they are not the same. Coding is somewhat subjective and it is not uncommon for one coder to read a complex chart and believe the care was primarily directed a one dx, while another coder my think that two dx were equally treated and use an alternative (more highly weighted) DRG.
I also just think it’s the wrong focus for CDI. I think setting such a high goal for a DRG match would actually direct the CDS to spend an extensive amount of time learning procedure coding, surgical hierarchies, and coding clinics that may not be necessary. This does nothing to actually ensure a complete record, which should be the goal of CDI.
You say a matching DRG indicates an optimized DRG and clear documentation? I don’t see that. I routinely see matching DRG's for coders/CDI on retrospective charts where there were query opportunities that would improve the DRG or clarify documentation. However, the CDI did not see it (or did not choose to query) and therefore the documentation is not in the record for the coder and they may not see the opportunity. Just having a matching DRG doesn't really indicate anything to me besides efficient use of an encoder. Don’t get me wrong, I get annoyed when I see blatantly wrong DRG assignment by CDI that obviously was not updated during the admission or shows lack of basic coding knowledge, but I certainly don’t think a matching DRG indicates good effort as a CDS.
That’s my two cents....
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
We approach from the standpoint of how a new CDS can lessen their learning curve, diligent reconciliation is necessary to see where you may have gone wrong in your DRG assignment and yes...since the course of treatment is fluid...many variables can affect the final outcome; but if you don't examine the final outcome, you can never fully identify opportunities and improve your process. This commitment to process improvement methodology is how a CDS moves from a novice to an expert. If you focus on a goal of 100% reconciliation on all cases for even a few months, you will likely uncover many areas in which CDI can have impact and then develop a business case for program growth and development.
Moreover, the driving influence behind our team and our organization is accuracy and quality of care. An accurate patient bill, final closure to our data integrity and the excellent services we provide, is an important part of our overall vision to provide a "remarkable patient experience, in every dimension, every time". I would encourage any program out there to look outside the box of any perceived CDI role; today's healthcare environment demands flexibility and increasing expertise in all facets of the patient encounter.
Abby
focus tends to emphasize SOI/ROM. We have a significant improvement
rate on that count.
Donna Kent, RN, BSN, CCDS
Manager, Clinical Documentation Integrity Program
Clinical Quality and Accreditation
Torrance Memorial Medical Center
ph.:310 784-6884 fax:310 784-6899
donna.kent@tmmc.com
Abby
For the many reasons Katy mentioned it does not seem realistic to hold the CDS responsible for matching the Final Coded DRG.
That being said, I think it completely depends on the focus of the program. Our focus seems to be much like Abby's Dept. We want that record coded as far as it can be coded before the Coder gets the chart. The Coder should not have to "diagnose" what happened in that record. If we are doing our jobs as CDS then we should be clarifying that documentation as much as possible. And that means reviewing those cases concurrently and tweaking that documentation and coding.
Having been an Inpt. Line Coder in the past I hold myself at a higher standard when I'm reviewing my Mismatches. I probably question more of my "Mismatched" DRGs than my co-workers do - its a matter of professional integrity. When I review those charts on the floor I try to think to myself, "what documentation would I need as a Coder to code this chart when I get it in my queue?" "What do I need clarified?"
However, Im glad Im not held to a rate! (But you never know...)
NBrunson, RHIA, CDIP,CCDS