Q&A: Know what to target when tracking top DRGs
Q: Can you recommend specifically what MS-DRGs are best to review and track or what CCs we should track?
A: I would review all admissions and all payers—this shows that your facility’s program is compliance-focused rather than revenue-focused (an important distinction to outside auditors).
You can identify what DRGs are in your top 25 and pay special attention to those, moving any of the symptom DRGs (chest pain, back pain, syncope, dizziness, abdominal pain, etc.) out of your top 25. This addresses several issues; it removes the low-weighted cases out of your overall CMI and identifies cases typically inappropriate for inpatient admissions.
From an internal auditing perspective, consider developing a report that identifies all the RAC targeted DRGs and abstract those records to validate the DRG assignments, either prior to, or after, billing.
An additional recommendation is to make sure that you validate the DRG for every case with only one MCC or CC. This should be a pre-bill process. Some of the target MCCs and CCs include:
- acute renal failure
- encephalopathy
- acute blood loss anemia
- atrial flutter
- malnutrition
- pneumonia
These are always query opportunities that may deliver higher reimbursement but with the RACs and other audit programs it’s more important that the documentation be consistent and compliant—and it’s important to make sure that the medical record documentation supports these conditions.
Editor’s Note: Lynne Spryszak, RN, CCDS, CPC-A, CDI Education Director, at HCPro Inc., in Marblehead, MA, answered this question. Contact her at lspryszak@hcpro.com.