Guest Post: The Problem List Project: Managing Post Acute Care Transfer DRGs

by Michele D. Johnson RN, BSN

The length of stay (LOS) for coronary artery bypass graft patients and valve replacement patients at York Hospital (YH)/ Wellspan Health was significantly higher than the Medicare geometric mean length of stay (GMLOS) according to results of a record review from October 2007 through December 2008. So the hospital administration formed a work team to identify why YH LOS differed so much from the transfer Medicare DRG GMLOS.

In early 2009,  the work team observed that post acute care transfer (PACT) DRGs resulted in a decrease of $4 million in our expected Medicare reimbursement in fiscal year (FY) 2008. After investigation, the work group determined that YH had an unexplained higher-than-expected distribution of cases in the cardiovascular service line with complications or comorbidity (CC) rates that affected DRG assignment.

The group reviewed a sample of 102 cases and determined that 32 of those cases had evidence of acute respiratory failure that were appropriately documented and coded. The YH physicians documented acute respiratory failure as the reason for a post operative pulmonary consult which increased in LOS as determined by the DRG formula; however, the assigned DRG and its associated GMLOS differed from YH clinical care standards.

After researching and reviewing the medical records, the documentation team found acute respiratory failure did not always, or even most of the time, actually increase patients’ LOS or use of resources.  The majority of the patients did not experience unexpected significant respiratory issues that required extended post cardiovascular surgery LOS.  In fact, many of our patients had shorter LOS than indicated by the Medicare GMLOS.

The documentation improvement team met with the pulmonary medical director to establish a better definition of acute respiratory failure that acknowledged DRG requirements. The CDI team helped the director understand how Medicare guidelines determine what diagnoses lead to increased LOS and emphasized the importance of documenting well-supported diagnoses.

The CDI team realized that the hospital staff lacked a common understanding of which co-morbidities affect the patients’ expected LOS.  To help facilitate awareness, the team developed a tool (available on the ACDIS Forms & Tools Library) to help identify and track pertinent medial issues with the patient’s working LOS. The team also developed a problem list tool to help identify DRG diagnoses with LOS timetables. A pilot program for the new problem list was implemented and incorporated into clinical rounds and medical record documentation.

The team tried to identify a probable discharge date for each patient ± 1 day.  The expected DRG and LOS also were incorporated into care management activities and staff communication during patient rounds.  We use the problem list to help us better manage the LOS and better understand the transfer DRGs.

Currently YH is working to incorporate the problem list into patients’ electronic health records. When the PACT DRG list was expanded in 2007, Medicare stated that the financial impact of the transfer DRG formula was neutral on hospital DRG reimbursement if DRG assignment is accurate. Our study suggests that this premise is valid and hospitals should assess documentation practices to ensure accurate final billing and coding.

Editor’s Note: Johnson, at the time of this article's release, was the documentation specialist supervisor at Wellspan Health in York, PA.