RE: CDS working DRG matching coding final DRG
Kimberly
I don’t know where you would find that, but for our institution, that information has gone by the way-side. We used to track it, as we were using a DRG based paper system relating to the CDI's and coders. We have now gone to a computerized system with the goal of QUALITY and not DRG based. (The CDI's at our institution always comment that "we are not coders").
For our institution, that information was so inaccurate, as often, we (the CDS) would assign a working DRG based on daily information in the chart and rounding. HOWEVER, as we all know "after study" is what pays the bills! So, in the CDS's assigning that working DRG daily we found that too often, when the pt discharge we did not have access to the discharge summary which OFTEN sheds light on the true nature of the diagnosis-so the DRG often changed once the coder has access to the discharge summary. For our institution we did not "hold" the paperwork to wait for that summary-it was an archaic system, and often the DRG's did not match.
We are now computerized and yes, we are able to track-with this system if a DRG matches, but the coders are now also able-under those circumstances, to place a REASON code for the DRG mismatch variation. They can choose:
-Subsequent Treatment or Documenation
-coding guidelines
-alternate PDX
-correct info, wrong DRG
-MCC/CC or procedure missed.
-query pending
This way, for education only, the CDS can see "if and why" we the DRG's did not match.
When we place queries the co-worker who trained me years ago would say "do you hear your job? You are not a coder, and it is not your job to get the DRG perfect". Generally we do very well relating to the assigning the same as the coders, but realistically being the type "A" personalities most of us are, it DOES help to know the reason the DRG did not match was due to something beyond our control!
Juli Bovard RN CDS
Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
719-4390 (work)
786-2677 (cell)
"No Limit to Better......"
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, October 05, 2011 11:22 AM
To: Bovard, Juli
Subject: [cdi_talk] CDS working DRG matiching coding final DRG
Can anyone help me with what may be the national average % for Clinical Documentation Specialist working DRG matching the Coder Final DRG. Or what the expected average may be?
Thanks so much,
Kimberly Strand, RN / CDS
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Copyright 2010
HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945
Regional Health's mission is to provide and support health care excellence in partnership with the communities we serve.
Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
I don’t know where you would find that, but for our institution, that information has gone by the way-side. We used to track it, as we were using a DRG based paper system relating to the CDI's and coders. We have now gone to a computerized system with the goal of QUALITY and not DRG based. (The CDI's at our institution always comment that "we are not coders").
For our institution, that information was so inaccurate, as often, we (the CDS) would assign a working DRG based on daily information in the chart and rounding. HOWEVER, as we all know "after study" is what pays the bills! So, in the CDS's assigning that working DRG daily we found that too often, when the pt discharge we did not have access to the discharge summary which OFTEN sheds light on the true nature of the diagnosis-so the DRG often changed once the coder has access to the discharge summary. For our institution we did not "hold" the paperwork to wait for that summary-it was an archaic system, and often the DRG's did not match.
We are now computerized and yes, we are able to track-with this system if a DRG matches, but the coders are now also able-under those circumstances, to place a REASON code for the DRG mismatch variation. They can choose:
-Subsequent Treatment or Documenation
-coding guidelines
-alternate PDX
-correct info, wrong DRG
-MCC/CC or procedure missed.
-query pending
This way, for education only, the CDS can see "if and why" we the DRG's did not match.
When we place queries the co-worker who trained me years ago would say "do you hear your job? You are not a coder, and it is not your job to get the DRG perfect". Generally we do very well relating to the assigning the same as the coders, but realistically being the type "A" personalities most of us are, it DOES help to know the reason the DRG did not match was due to something beyond our control!
Juli Bovard RN CDS
Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
719-4390 (work)
786-2677 (cell)
"No Limit to Better......"
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, October 05, 2011 11:22 AM
To: Bovard, Juli
Subject: [cdi_talk] CDS working DRG matiching coding final DRG
Can anyone help me with what may be the national average % for Clinical Documentation Specialist working DRG matching the Coder Final DRG. Or what the expected average may be?
Thanks so much,
Kimberly Strand, RN / CDS
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com
If you would like to be removed from CDI Talk, please send a blank email to
leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2010
HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945
Regional Health's mission is to provide and support health care excellence in partnership with the communities we serve.
Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
Comments
Renee
Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center
Hope your program grows in the directions you hope!
juli
Kimberly