Negative impacts on queries

There are instances where if the initial primary diagnosis for a case goes to a signs and symptoms DRG and  CDI queries for a more definitive primary diagnosis for admission, the result goes to a lower weighted DRG thus resulting in a negative financial impact. My team has questions on whether we should take these negative financial impact on our cases. I would like to know how other facilities are dealing with these situations. should we take the negative impact?


  • Our program never claims a negative variance for obtaining clarification and accuracy in the chart. We usually create the coding options exactly alike with the correct documentation (physician response) captured in both options so that our CDI tool will calculate this as what we call a "washout". DRG is the same in both coding options, with no financial variance. I hope this makes sense.

    Hillary Guidry RN, BSN, CDIP

    Ochsner Lafayette General

  • Good Morning, this is a great question. Making the record accurate correct is our goal. We know that often sign and symptom diagnoses may have a higher relative weight than the true medical diagnosis. Also, we see this issue when overdocumentation occurs. For instance, when a provider has documented sepsis but there are not strong clinical indicators to support sepsis, the clinical documentation specialist (CDS) often sends a clinical validation query. If the provider rules sepsis out, it will look like a negative shift. In fact, what really occurred is, the query helped to substantiate the record and prevent a future DRG downgrade. We do not subtract these dollars from our overall reimbursement but use this data to track where we may have compliance issues for documentation. This data is great at helping the CDS know where to educate providers.

    Jeanne Johnson

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