CDS and DRGs

Unknown
edited May 2016 in CDI Talk Archive
Does anyone working as a CDS NOT compute DRGs? At my facility, we do.
However, sometimes our working DRG and final DRG post query are
different from the coder's final DRG. For financial reporting, this
creates a discrepancy in our potential impact. The report shows that we
had a potential to move something, when in fact we may not have at all,
because our DRGs were wrong. We are not "coders" and don't always match
the coder's DRG, or things change after we see them (PDX changes,
surgery hapened, etc.). Our physicians are now being looked at more
closely (finally) and I'd like our reports to be as accurate as
possible. One thought I had was to only encode cases we query. We use
3M stand alone encoders on the floor with us. I could still track our
productivity without entering a DRG. I don't see the importance of
encoding if we don't query. Just trying to reduce our report errors.
Looking forward to hearing how everyone does their process.

Stacey Forgensi, RN, CCRN, CCDS
Clinical Documentation Specialist
Erie County Medical Center
sforgens@ecmc.edu
Pager 642-1011



Comments

  • mannb1mannb1
    edited May 2016
    As CDS, we do compute the DRGs, and often (although we are improving!) our DRGs don't always match the Coder's DRGs. If we query, our reports also show the potential impact we could have made, and whether or not the provider agreed/clarified the query. We discuss the mismatches with the coders, and if we agree with their final code, will reconcile our DRG to match theirs. On the reverse, if the coder agrees with us, they will change the abstract/final billing to our DRG. If we can't agree, we have the coding manager or physician liaison review the case. We, too, use 3M stand alone, but don't enter every case into it. We use Navigant consulting tool: MS-DRG Navigator to arrive at best DRG, but will use 3M for surgery cases, unusual diagnoses, or to see if something may actually act as CC/MCC.


  • Unknown
    edited May 2016
    Thanks Becky,
    We might have to try and reconcile our DRGS with the coders for more
    accurate reporting.

    Stacey Forgensi, RN, CCRN, CCDS
    Clinical Documentation Specialist
    Erie County Medical Center
    sforgens@ecmc.edu
    Pager 642-1011



  • kari.eskenskari.eskens
    edited May 2016
    Our CDS do not calculate a DRG, ever. They know the MCC and CC and diagnoses that need to be further clarified. If they are doing their part to get accurate and complete documentation, the coders will do their job and arrive at the DRG. I want the CDS staff reviewing charts, talking with MD's and querying charts - good documentation is good documentation regardless of what the DRG is.
    We have monthly meetings with the CDI staff and Coding staff to discuss coding questions and documentation areas. We will review cases and do a retrospective "what if" discussion. These have been very helpful.

    Kari L. Eskens, RHIA
    BryanLGH Medical Center
    Coding & Clinical Documentation Manager


  • Unknown
    edited May 2016
    My thoughts exactly. I'm not sure I see the need to calculate DRGs,
    especially on cases not queried at all.

    Stacey Forgensi, RN, CCRN, CCDS
    Clinical Documentation Specialist
    Erie County Medical Center
    sforgens@ecmc.edu
    Pager 642-1011



  • mannb1mannb1
    edited May 2016
    Kari,
    Just curious - and this is a silly question (so forgive me!) - if your CDS staff doesn't calculate the DRGs, are they still knowledgeable about the DRGs and the MDC listings? The reason I am asking, is that when I discussed this option for doing CDI w/our consultant, her question was: "how will those CDS who don't calculate the DRGs be able to sit for the CCDS exam, if they aren't aware of the DRGs?" Personally, I LOVE the idea of not calculating (often guessing) the DRGs, as I agree with you that the CDS's role is to get the best documentation from the providers & have those clinical conversations - as we aren't coders.


  • shoffmanshoffman
    edited May 2016
    Concurrent coding serves a very important function. It provides the LOS.
    Our Case management department relies on these estimated LOS calculations.




    Sylvia Hoffman R.N.
    Clinical Documentation Specialist
    Tampa General Hospital
    Phone 610-4818




  • Unknown
    edited May 2016
    Maybe the CCDS exam needs to be re-looked at if not everyone is
    calculating the DRGs. The purpose of a CDI program is ultimately
    getting good documentation. When I took the exam, there were many
    administrative type questions that I was not privy to where I work that
    I felt were more managerial/coder related. Our program has been in
    existence for three years, and we have already proven the financial
    worth with our reporting. I wonder if it isn't more beneficial to
    concentrate our efforts strictly on the documentation. Our CDS' often
    get DRGs wrong and the impact is not shown on the reports anyways. The
    same goes for retro queries, where we have to track it separately. To
    compound the problem at my hospital, we have three payors - medicare, AP
    and we just introduced APR in December. With different rules for each
    and insurances constantly changing, our DRGS are wrong more than right.
    Personally, I could hit a lot more charts if I weren't encoding. Any
    thoughts from anyone else?

    Stacey Forgensi, RN, CCRN, CCDS
    Clinical Documentation Specialist
    Erie County Medical Center
    sforgens@ecmc.edu
    Pager 642-1011



  • Unknown
    edited May 2016
    Our concurrent coding isn't reported to anyone, we're not coders. Our
    coders do not do concurrent coding.

    Stacey Forgensi, RN, CCRN, CCDS
    Clinical Documentation Specialist
    Erie County Medical Center
    sforgens@ecmc.edu
    Pager 642-1011



  • bonnie.diehrbonnie.diehr
    edited May 2016
    Dear All:



    Last year I asked if anyone was tracking their documentation impact from
    the CDS program in their hospitals. Most hospitals replied that the
    Documentation Specialist kept their own on their laptops. However, one
    hospital in New York shared a spreadsheet/program that they used to
    track the working DRG versus the Final coded DRG with all the variables
    that were being reported to the hospital Finance Department. Does
    anyone remember this and if so could you share the program/spreadsheet
    with me again?



    Thanks

    Bonnie Diehr

    HIMS Coding Supervisor

    Martha Jefferson Hospital

    Bonnie.Diehr@mjh.org








  • kari.eskenskari.eskens
    edited May 2016
    They are familiar with DRG's, pry not as in depth as those that do calculate DRG's. They understand that there is a different DRG for MI with cath, with CABG, MCC etc.. but couldn't cite you the specific DRG numbers. We started our training with them in the DRG books so they could learn this reimbursement system and logic. Also, in our monthly review meetings, we do use the coding software and review DRG's and areas for opportunity.

    They do have access to the encoder that the coding staff uses and can use it as a tool, as well as the DRG Expert book. But, as someone stated before, they are not expected to be coders.

    Kari L. Eskens, RHIA
    BryanLGH Medical Center
    Coding & Clinical Documentation Manager


  • tiffany_susantiffany_susan
    edited May 2016
    How do you show dept impact?

    Thank you,
    Susan Tiffany RN, CDS
    Supervisor
    Clinical Documentation Program
    Robert Packer Hospital & Corning Hospital
    570-882-6094 pager 465
    Fax 570-882-6768
    Tiffany_Susan@guthrie.org





  • epraczepracz
    The test should not be based on the correct DRG but the process. We had a consult 5yrs ago and we used to figure out DRG
  • Unknown
    edited May 2016
    We use the 3M encoder but we do not put enter any codes if we don'tt
    query. That saves time. If I have to, I take the codes out of the
    encoder prior to the record being coded. If the codes are in the EPIC
    system and they check coding hx, it will have a code we queried for.
    The code was just easier. We track on an Excel spreadsheet the working
    and final and then reconcile the DRG's to determine if there are any
    educational opportunities for either coding or CDS. If the coders don't
    pick up a MCC we did then we review the case and sometimes the coders do
    not wish to code it because they do not believe it is documented enough.






    Carla A. Heyn, RHIT, BS

    Clinical Documentation Specialist

    Elliot Hospital

    One Elliot Way

    Manchester, NH 03103

    603-663-3452

    cheyn@Elliot-HS.org








  • Unknown
    edited May 2016
    Kari ,

    How do you show your impact? Or $ etc.?



    Carla A. Heyn, RHIT, BS

    Clinical Documentation Specialist

    Elliot Hospital

    One Elliot Way

    Manchester, NH 03103

    603-663-3452

    cheyn@Elliot-HS.org



  • Unknown
    edited May 2016
    The test should be related to both coders and nurses because both can be
    CDS's. The documentation justifies the level of DRG. Just a thought!




  • Unknown
    edited May 2016
    That would be interesting. I would also like to see that if it could be
    shared.



    Carla A. Heyn, RHIT, BS

    Clinical Documentation Specialist

    Elliot Hospital

    One Elliot Way

    Manchester, NH 03103

    603-663-3452

    cheyn@Elliot-HS.org



  • dogdog
    I don't know if the test can be all things to all people. For example, there were spreadsheet questions, but I don't use spreadsheets in my job, yet I was still able to answer them. Just like when I took the CCRN exam and I was a cardiology nurse but had to answer neuro questions.

    As for DRGs, I am required to calculate them, and if I differ from the coders for any reason other than additional information that wasn't available to me during my review, I am considered to be wrong and must document that I was in error. Of course I argue my side if I feel confident in it, and often I get them to change their mind based on my clinical analysis, but sometimes they are just as right in their view as I am in mine--a tie goes to the coders.

    I used to care, because those statistics are tracked, but I honestly don't give a good doggone any more. If I captured an MCC due to my work, then I recalculate the DRG based on what the coders would have gotten without my query and adjust the impact accordingly. I also take an impact if the coders upgrade the DRG based on my analysis or if I find a code that they missed. I think impact is vastly overrated, but it's what the beancounters in administration are looking for and it's how the CDMP program is sold to them.

    I agree with the earlier poster who said that even if you don't calculate DRGs as part of your job, you should still have a very solid understanding of how they are calculated and what they mean.

    Renee

    Linda Renee Brown, RN, CCRN, CCDS
    Clinical Documentation Specialist
    Arizona Heart Hospital
  • shoffmanshoffman
    edited May 2016
    I agree with Linda. Prior to doing Concurrent coding I was responsible
    for identifying the DRG and knowing if I needed a CC or MCC. The switch
    to coding was in not way easy for this RN, but I had a good base knowlege.
    The Test is not biased one way or the other. Everyone shares in the pain
    of having their knowlege judged by a third party. If it were easy any
    one could be certified.




    Sylvia Hoffman R.N.
    Clinical Documentation Specialist
    Tampa General Hospital
    Phone 610-4818


  • ssandstromssandstrom
    edited May 2016
    Renee,

    I calculate the same way you do. If the final DRG is different than what I thought it would be, I use that one to re calculate my impact from queries.


    Sharyn Sandstrom, RN-BC
    Clinical Documentation Specialist
    Carteret General Hospital




  • michele.goossenmichele.goossen
    edited May 2016
    At our facility each CDI tracks their own cases and reconciles them once the case is finalized by the coder. If their is a discrepancy the CDI determines what caused the discrepancy (CDI error, information that was not available at the time of the review, a procedure done after our review, the physician changed the PDX, missed CC/MCC, coder chose a different PDX ect). Cases we believe were coded incorrectly we discuss with the coder or take them to our weekly team meeting. For FY 09 the financial impact was very high on the cases that were re-billed.

    We also review every pre-bill surgical case that does not have a CC &/or MCC. The financial impact has also been very high in this area (Missed CC & MCC or needed queries placed).

    All the CDI's place their information (positive & negative impact from DRG changes, surgical cc reviews & queries) on a master spreadsheet. Our manager passes the financial impact information on to everyone she has to report to.

    Michele Goossen, RN, BSN, CHCQM
    Clinical Documentation Specialist
    Lakeland Regional Medical Center
    863-687-1369



  • tiffany_susantiffany_susan
    edited May 2016
    You are so right!! I agree there needs to be an understanding of the
    process, but, the more time and energy spent on getting to the right DRG
    takes away from the number of charts reviewed and the quality of reviews!
    We just had a group discussion that , bottom line, my CDS was working hard
    to determine PDX, when there was no impact on the chart (the chart all
    ready had multiple organ failure, with good documentation). There were no
    quality issues, no impact potential .... just the need to match the coders
    final DRG ............... Seems to such a huge waste of resources!

    Thank you,
    Susan Tiffany RN, CDS
    Supervisor
    Clinical Documentation Program
    Robert Packer Hospital & Corning Hospital
    570-882-6094 pager 465
    Fax 570-882-6768
    Tiffany_Susan@guthrie.org





  • Unknown
    edited May 2016
    Agree Susan, our CDS' do the same thing. I could see a lot more charts
    if I wasn't worried about matching the DRG.

    Stacey Forgensi, RN, CCRN, CCDS
    Clinical Documentation Specialist
    Erie County Medical Center
    sforgens@ecmc.edu
    Pager 642-1011



  • dsmith12h@aol.comdsmith12h@aol.com
    edited May 2016
    We reconcile DRG's once the coders have coded. There are times when we have queried and the coders have missed a "cc/mcc" that we've captured with the query. There are other times that codes changed resulting in DRG changes, we think it's a good check/balance process.






  • kari.eskenskari.eskens
    edited May 2016
    We do a retrospective review to determine the impact. One member of the CDS team is an RHIA/CCS. She tracks all queries in excel. She reviews the final coding assigned by coding staff to ensure dx from query was captured, and if not captured why; these are the items we discuss at the monthly meetings. If the dx that CDI queried for is the only MCC or CC on the case and caused it to group to a higher paying DRG, CDI gets the "credit" for that increase. We also track how many cases resulted in an add'l MCC/CC that would show an increased severity of the patient, but did not impact reimbursement.

    This tracking is a manual process, but works well for us. It allows feedback to CDI and coding staff and ensures good quality throughout the entire process. Neither one of these groups can be successful without learning from each other.

    Kari L. Eskens, RHIA
    BryanLGH Medical Center
    Coding & Clinical Documentation Manager


  • dbutlerdbutler
    edited May 2016
    Though I agree with the concept of not spending time determining the PDX/DRG, that has to be balanced against the recognition that unless one has an accurate idea of the DRG supported by the current documentation, one does not have the direction of where to prioritize efforts without that accurate idea.
    Seems to be a balance and a quandry.

    We also had many of the issues related to 'right vs wrong' DRG and stopped keeping track of that specific metric, which helped morale, improved team work, etc. without really loosing productivity or impact (probably better but don't have data to directly support).

    I strongly agree that to determine impact (financial or SOI), the coding gained from CDI activity has to be compared against the BILLED DRG, not the working DRG. I would suggest it is NEVER safe to measure impact using the working DRG.

    Don

    Donald A. Butler
    Manager, Clinical Documentation
    Pitt County Memorial Hospital
    Greenville NC
    252-847-6855



  • fishdl@shands.ufl.edufishdl@shands.ufl.edu
    edited May 2016
    Our CDI Team consists of two certified coders and two RNs. Our program
    reports to the HIM Department and was started by a coder (me) who knew
    the frustration of trying to assign codes for conditions that are
    clearly present & treated but not documented in a "codeable" manner or
    lacked the required specificity. As I'm sure many of you know, querying
    the physicians retrospectively is much more difficult (and interrupts
    the revenue cycle) than writing a concurrent query or being able to
    discuss with them face-to-face. Since starting the program five years
    ago, another certified coder and two RNs joined the team. We all use 3M
    to concurrently code our records into the actual patient account so when
    the coders get the records after discharge, they can see what we coded.
    They can also see which records were queried, why, and where the MD
    response is documented. Concurrently coding the record also establishes
    a working MS-DRG with the associated GMLOS which is available to Case
    Management to help with LOS targets. We also use the APR-DRG software
    which requires that all conditions and co-morbidities are coded to
    establish reliable severity of illness & risk of mortality (SOI/ROM)
    scores. Having this information opens up new opportunities for
    physician queries to ensure our risk adjustment and public quality
    measures are accurate.
    We demonstrate our risk adjustment and financial impact by comparing
    the APR-DRG scores and the MS-DRG payment difference before and after
    our intervention (queries). The information interfaces from our
    Documentation Review screen in Softmed/Clintrac to our impact reports.
    Our monthly reconciliation focuses on the accounts we queried - not
    every account we touch. If there is a discrepancy between our working
    MS-DRG and the final coded MS-DRG, we review the record to determine the
    reason. If we missed something, we make adjustments to our report. If
    we believe the coder missed something, we discuss with them until it is
    resolved. For any account, if the coder has a question regarding our
    code/MS-DRG assignment, we welcome their questions and use Trillian's IM
    service to communicate.
    Our productivity (number of reviews and queries) is measured
    automatically each time we make an entry in the Documentation Review
    screen.
    Admittedly, concurrent coding of the records takes quite a bit longer
    than just reviewing them, but our goal is to provide the most clear,
    concise, and complete record at discharge.
    Donna


    Donna Fisher, CCS, CCDS
    Lead Clinical Documentation Improvement Specialist
    Health Information & Record Management
    Shands Healthcare at the University of Florida
    352-265-0680 Ext 48769
    fishdl@shands.ufl.edu


  • robert.hodges2robert.hodges2
    edited May 2016
    Kari,



    I do something similar to what you do. The inpatient coder gets a copy
    of all my queries and then at the end of each month lets me know if the
    query impacted by MCC/CC capture or some other change. I don't worry
    too much about DRG match, but I do go back and record the final coded
    DRG and ICD-9 codes in my database for education. An added benefit to
    this is that I've caught a few bugs in the software the coders used
    where a CC/MCC is coded, but not captured in the final DRG. It takes
    time and is all manual, but there are benefits for everyone in doing it.



    Robert



    Robert S. Hodges, BSN, MSN, RN

    Clinical Documentation Improvement Specialist

    Aleda E. Lutz VAMC

    Mail Code 136

    1500 Weiss Street

    Saginaw MI 48602



    P: 989-497-2500 x13101

    F: 989-321-4912

    E: Robert.Hodges2@va.gov



    "Anyone who has never made a mistake has never tried anything new."
    -Albert Einstein




  • nbrunson84nbrunson84
    edited May 2016
    Our setup is a bit more different as we are doing the initial and
    concurrent Coding as well as querying for documentation. I know which
    PDx/DRG will need an MCC or CC to affect the case. We do not calculate
    DRG's by hand - our coding software does that.



    I do know when I performed UM - (and also concurrent coded to receive
    GMLOS) - I needed the correct DRG to get my "days". But again, this was
    done by the coding software. I haven't had to calculate DRG's since
    school some "mumble, mumble" years ago.



    I print out my con-current list each day and give to the appropriate CM
    following that floor. I know she uses it to get her LOS for her
    patients. If she knew her DRG's etc. she wouldn't need my report...
    :-)



    Off and on we have performed some "documentation" program for years. We
    always called it "concurrent coding". It has been under Quality, UM,
    CM, Med. Rec. - you name it. It would start - go for a while - and
    discontinue with the next wave of Healthcare. However, I will say, it
    has never "hurt" me to know my DRG's.



    (Until FY 2008 when we went to MS DRG's - then all those DRG's I had
    memorized were "null and void" and I have to memorize all the knew
    ones!!)





    N. Brunson, RHIA

    Clinical Documentation Specialist

    Bay Medical Center


  • nbrunson84nbrunson84
    edited May 2016
    Donna - our setup is very much (almost exactly) like yours!! Glad to
    see you with that CCDS after your name!!



    "Admittedly, concurrent coding of the records takes quite a bit longer
    than just reviewing them, but our goal is to provide the clearest,
    concise, and complete record at discharge."





    This is our goal as well! So glad someone else is doing it also!



    Does your 3M software (we use Quadramed) calculate your severity score
    where you can be aware of it? I think our Quadramed software does this
    - but we need to "toggle" something within the setup! :-)









    Norma T. Brunson, RHIA

    Clinical Documentation Specialist

    Bay Medical Center


  • fishdl@shands.ufl.edufishdl@shands.ufl.edu
    edited May 2016
    Norma - Thanks for your response. Frankly, it worries me a bit that, at least from some of the recent posts, many programs seem to be drifting away from establishing working MS-DRGs and proving/reporting their impact (public quality measures, financial, return on investment, etc...) With every review, I strive to keep my customers' needs in mind - I consider the coders, the hospital's publicly reported quality data, and the hospital's revenue cycle to be my primary customers since what we do - directly impacts them.
    To answer your question about severity scores - the APR-DRG grouper is a 3M product which we purchased in addition to the 3M Encoder. When we enter codes and calculate the MS-DRG, it also automatically calculates the SOI/ROM scores for us based on all the diagnoses and procedure codes entered. It's calculation methodology is much more complex than for the MS-DRG, and for the most part, is impossible to predict which diagnoses and/or procedures are going to impact the score. We use 3M's Advanced Analyzer to help identify those conditions and procedures, which if present, will impact severity and/or risk. This results in additional query opportunities. In addition to the MS-DRG, the APR-DRG and SOI/ROM scores are displayed on our encoder summary screen. This is especially beneficial when reviewing mortality charts. If the risk of mortality score is not - 4 (extreme), I know I need to "dig a little deeper".
    Hope this helps.
    Donna

    Donna Fisher, CCS, CCDS
    Lead Clinical Documentation Improvement Specialist
    Health Information & Record Management
    Shands Healthcare at the University of Florida
    352-265-0680 Ext 48769
    fishdl@shands.ufl.edu



  • dallend@einstein.edudallend@einstein.edu
    edited May 2016
    Our program is 8 almost 8 yrs old. In the first 4 years we did establish DRGs. We stopped about 4 years ago. However, we continue to measure our impact by looking at query impact, our SOI/ROM and our CMI. We do not have to worry about LOS - that is the responsibility of care management.
    We work closely with our coders to ensure our charts are as clean as possible. We query to establish a chart that accurately reflects a patients condition and the treatment rendered. We review our charts after coding has been completed to ensure that nothing has been missed. Our compliance auditor reviews our charts that are coded with no cc/mcc - we will query, if needed, on those charts. She will also pass charts back to the coders if a diagnosis was missed.
    I think there are many ways to measure the value of a CDI program. Each facility should do what works best for them and their CDI and coding staff.


Sign In or Register to comment.