Q&A: CDI/coding DRG match rates

Q: We use the pre-bill reconciliation process at the time of coding and are trying to determine the true CDI/coding match rate. If the CDI specialist doesn’t enter the queried diagnosis in their working DRG but the physician responds favorably to the queried diagnosis at the time of coding (and/or during the retrospective query process) would you consider this in the reconciliation process? If yes, how would we capture this type of data? 

A: Let’s clear up any potential confusion regarding the definitions for “working DRG” and “queried DRG.”

A working DRG represents the initial DRG that would have been assigned prior to the CDI specialist’s record review and query efforts.

A queried DRG represents what would be assigned due to the query process if the physician agrees and answers the query (whether on the query form itself or in the medical record) and it results in a change to the working DRG.

Consider the patient who came in with chest pain. Their working DRG would be DRG 313. Then, the CDI specialist queries for the cause of the chest pain and the physician answers that the patient had an acute myocardial infarction (AMI), which would then make the queried DRG 282. Once the chart is final coded by the coding staff, the final DRG 282 is assigned.

I was always taught that to do the reconciliation process you would compare the queried DRG to the final DRG. In the example I just gave, the result would be a match, but if you compared the working DRG to the final DRG, you would have a mismatch.

My department used to also compare the different DRGs (initial/working to queried) to show the CDI department’s impact. If the CDI specialist reviewed the chart and, based on information in the chart, queried the physician, which resulted in a different DRG being assigned as the final DRG, then the CDI specialist had an impact.

Not every facility does the reconciliation process the same way, though. So, make sure you and your team all understand the definitions in place for your program. For example, some teams call the “query DRG” the “working DRG;” and the “initial DRG” just the “initial DRG.”

Also, some facilities allow the CDI specialist to submit up to three DRGs, and if any of these match the final DRG, it’s considered a match while still other facilities require a one-to-one match.

Editor’s Note: Sharme Brodie RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.