DRG and Utilization Review

Unknown

I have a couple questions.

About 6 months ago our facility joined the DRG and UR departments and have the clinical reviewers performing both functions simultaneously. Do any of you conduct both reviews and if so, how do you operationalize it?

We started our DRG program 6 years ago. Initially, the DRG reviewer would select the working DRG's. Two years ago, we moved away from having the reviewer select any DRG codes (DRG selection is left to the coding specialists) and concentrated on clinical documentation improvement, getting more specificity, querying etc. Has anyone else made this change and how has it worked out?

Our facility is considering going back to separating the DRG and UR functions with separate staff and also returning to having the reviewer select DRG's, in order to use a computerized DRG program.

Thanks,
Katherine Stummer, RN CCDS
Clinical Reviewer
UR/DRG Program
St. Joseph's Hospital Health Center
Syracuse, NY

kelleywalrath

Katherine.

I would think that would be difficult to combine the complete role of documentation specialists with that of UR as both are very complicated and getting more so as ICD 10 Comes into place. Traditionally programs that have done this have found documentation has been the lower priority. Perhaps that would not be the case with you since you've been separated for awhile and realize the importance of the document specialist role. I am not quite sure why you are doing things simultaneously.

Our organization does report to case management so they have had us doing some things in quality and also now in trying to convert some outpatients into in patients through getting the physician to document more thoroughly and considering such things as patient safety, extensiveness of testing and consults, and complexity. We have to train the physicians to consider these factors and to separate a section of their H&P to include their rationale for hospitalization. So if the patient does not meet the requirements of Interqual, perhaps with the increased documentation, they can, based on medical necessity.

We do not assign the DRG either after MS DRG's came into place. We found it better to focus on finding a proper principal diagnosis and co morbidities and complication codes over trying to get DRG just right. It seems to be easier for the coders to leave the DRG assignment to them. There was less disagreement.
I don't know if I fully understand what you are doing but hope I have been of some help.


Kelley Walrath RN CCDS
Munroe regional medical Center
Ocala, Florida
352-671-2589

vanessa.falkoff

Hi all,

I would be very interested in knowing how many other programs in addition to Katherine and Kelly's used to assign a DRG, but have now stopped, and if you have seen success. My program is less than a year old and the consulting company recommends DRG assignment plus a whole lot of other data tracking which seems excessive for a one person CDI department in a hospital with over 500 beds.

Thanks in advance!

Vanessa Falkoff, RN
Clinical Documentation Coordinator
University Medical Center Southern Nevada
Las Vegas, NV
office (702) 383-7322
cell (702) 204-0054
vanessa.falkoff@umcsn.com

sabullock

We still assign a working DRG and look at our SOI/ROM with APR-DRG. What we have stopped doing is the DRG match to final coding piece. This was very time consuming post discharge. It was a great teaching tool for all but going to all payer review we had to scarifice something.

Shelia

dbutler

Vanessa,

Let me point you to a couple of items that will address your question. ACDIS On line poll archives has a poll (#80, 3/2010) asking "Do you assign working DRGs to cases?" -- 81% yes, 11% no, 8% used to but stopped.

The 2010 Physician Query Benchmarking Report (find on the website with the Quarterly Journal, Jan 2011). Look specifically at fig 27 -- Which of the following do you audit/monitor as indicators for query performance (check all that apply)? two bars specifically: 60% CDS.coder agreement & 78% Final DRG. This document has a lot of very good benchmarking information that you might find helpful as a new(er) program.

We do assign working DRGs, but don't calculate the CDS/coder agreement rate. It is helpful as a prompt for education (both self as well as feedback). We also find it useful to help guide where limited attention and resources need to be directed (as part of the individual's daily work flow & process)

Don

Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com

vanessa.falkoff

Thank so much Don and Happy Holidays to you!

lspryszak

I am not a big fan of having to assign a DRG because a certain program is based on obtaining this data. For one thing, comparing DRGs take time -- in order for any data to be meaningful, someone has to validate the starting DRG against the final coded DRG. for example, if the last assigned concurrent DRG was medical and the final DRG was surgical, was that DRG change due to the CDS? No. The patient would have had surgery anyway. So then someone has to analyze the coding summary to see whether a query was involved. Did the query affect the final DRG? Maybe -- if the query was responsible for the ONLY Cc or MCC. Then you'd have to go back and change the last concurrent MEDICAL DRG to a surgical DRG so that you'd be measuring the change in SURGICAL DRGs: maybe going from w/out a Cc/MCC to one with a CC or MCC.

Is all this effort really worth it? Most mature programs say "No" and have abandoned tracking this.

You can certainly see the influence of CDI in LONGITUDINAL (year-to-year average) CMI change - once you've neutralized your data to eliminate those things CDI can't impact: change in service lines, change in surgical volumes, seasonal variances, etcetera.

Facilities, or rather, administrators, seem to like seeing reports showing that their CDI team "captured" or "recouped" additional revenue based on individual or monthly DRG changes. Reporting this type of information is a HUGE mistake!

Unless you analyze every record for discharge disposition to ensure that your facility receives the ENTIRE DRG payment for a case (or cases), any such financial figures calculated on DRG change are at best, + or - 25% of the figure you come up with. If the variance is that much, then what's the point of measuring it at all??

Okay -- getting off my soapbox now...

evanspx@sutterhealth.org

I also feel that the time it takes to compare the CDI working DRG to any final DRG assigned by HIM/Coding is time-consuming and of questionable value.

I believe the purpose of CDI to initiate a query for all of the reasons we all know and accept - if this results in a 'positive' DRG impact, that is good. But, to track the true $$ amount that can be attributed to CDI is costly and difficult. You have to take many factors into account. If not done with caution, the dollar impact of CDI efforts can easily be misreported.

Paul Evans, RHIA, CCS, CCS-P

Unknown

Thank you who ever you are, no signature visable.

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

dbutler

A number of good points & I certainly find myself in agreement with much of your discussion.

I'd like to advance the argument that there is a reasonable way to capture the information regarding financial shifts that the CDI program gains. In part, I'm playing devil's advocate. I'm also suggesting a slightly different approach.

I agree that the effort to accurately compare the CDI working DRG to final coded is very time consuming and costly.

We don't do that. What we do, is to follow a very similar process but ONLY for those cases where a CDS did pose a query. First, determine what information is in the record and is codable that is highly likely if not certainly due to the CDS efforts. Second, determine (starting from the final coded DRG) what the DRG would have been with out the CDS query result. Then, calculate the financial gain between the hypothetical DRG and the billed DRG. Yes, quite a bit of work, needs to be done with care, and needs to be audited to ensure the data analysis is done well. However, does provide a reasonably accurate measure.

With this approach, to be honest, how many cases need this kind of analysis? 15 to 25%? If the average CDS reviews 150 cases a month, then we're talking about somewhere in the ballpark of 30 cases a month, and should take no more than an hour or two a week. Only the cases that have been queried, and not all of those will need the full analysis -- if the query was for a cc, and the final DRG is an MCC split only, then no further analysis is needed.

I would suggest that the effort involved to 'adjust' the year over year data is just as difficult, and has variables that can't be controlled or accurately adjusted for just as is inherent to what I've described above. In part, it is a matter of preference. In another part, it is a matter of what data analytics one can call upon to help with this adjustment or neutralization process. Not everyone can do this, but any CDI program can do what I've described.

Another aspect, not all organization leadership are willing to forego the financial measures of a CDI program effectiveness.

I agree regards the aspect of disposition & I certainly haven't figured out a good answer to that problem from an accurate data reporting perspective -- but when one is being asked or required to report financial metrics, the only recourse is to be sure to repeat this caveat over and over.

There are all sorts of other benefits of a CDI program that are not so easily measured -- building a stronger medical record with better documentation helps to ensure 'depth of defense' with RAC, ensure that what is coded and billed more accurately reflects the clinical reality so there is stronger revenue integrity, more accurate ROM/SOI profiling, etc. Many of these benefits are simply more difficult to measure or require specific software tools, or are delayed in the availability of the data, etc.

Don

dbutler

Deliberately responding with this question separately, as I am genuinely curious and want to know, and am concerned this question will be lost in my other response.

I would like to ask, what metrics does your program report? and how is the data captured and the analysis completed so there is not the level of effort, time & cost as is often accurately associated with the financial metrics we're discussing?

Don

Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com

cynthia.a.goewey

Hi Don,
Our program uses the process you described. We only need to compare our DRG's to the final coded DRG on the cases we queried on. I have been doing this process for over 3 years now and do not find it takes up a lot of my time, I would say a maximum of 1 hour/week. When our working DRG doesn't match the coders final DRG they contact us if they do not see an obvious reason why (such as our pdx was ruled out during the stay, a patient had a procedure we didn't capture, etc). We will then quickly review the case and respond back to the coder if we agree with their DRG or not. If we don't agree we discuss the case together and come to resolution.
I agree there are many aspects to CDI but I do not see the financial impact of a CDI program disappearing off senior leaderships screen. Our organization has offered early retirement and then still had to lay off staff with yet another lay off coming. We would be kidding ourselves if we think that there is not a close eye on the financial impact of any program in the hospital...especially one that has the potential to increase revenue. I do not mind that focus as long as it is recognized that we do more than just impact the bottom line.

Cindy

kelleywalrath

We do focus on financial aspects primarily. We study the pepper report and try to adjust our focus accordingly. We do measure what those would be DRGs against the final DRG had we not queried. This is the guesstimate based on six years of seeing how things typically get coded. So though we do not send to coding the DRG, we do very much compare the DRGs. It just got to be frustrating for the coders if we did not send the right DRG. But we do have our own DRG in our system. We also measure the percent of queries per patients seen, the total number of queries per month per CDI, how many impacts the CDI made in changing the DRG, and the answer rate. We also look for SOI/ROM but do not measure that at this time.

kelleywalrath

I apologize for not leaving my name etc.

Kelley Walrath
Munroe Regional medical Center
Ocala Florida
352-671-2589