Q&A: When to conduct a follow-up review

Q: If a patient is in a three-tiered DRG, but has a three-day length of stay (LOS), is it correct that the next review need not occur till the LOS equals or exceeds three days? Do we need to capture a possible CC or MCC?

A: First thing you need to know is the mission of your CDI department. This mission statement dictates how often you conduct follow-up reviews. Internal CDI and coding policies regarding timing of reviews also need to be followed.

Usually, if the CDI program’s mission is financially focused, CDI specialists need to review the medical record until you reach the highest level of a DRG type. This is done with the addition of either a CC or MCC.

Now, if the mission of your CDI department is both financial and quality focused, medical records need to be reviewed from admission to discharge, capturing all diagnoses to determine a patient’s severity of illness (SOI) and risk of mortality (ROM). The goal here is achieving a score of SOI-4/ROM-4, and maximizing the DRG with CC/MCC additions.

Usually, CDI staff complete an initial medical record review within the first 24-48 hours after admission. The working DRG assigned at that time should provide some indication of when to conduct the next review.

For example, if the working DRG assigned is a sign or symptom, then the next review would likely be the following day. Looking at the patient’s LOS helps us make the determination of when we should next review a chart. If you do the initial review 24 hours after admission and the patient has a LOS of three days, then you can either do another review on the day of discharge or wait and see if the patient is discharged. If they are discharged on time, then you would be done. If they are not discharged, however, the next step would be to find out if the reason was related to a discharge issue, meaning they can’t place the patient, or if the patient’s condition changed and prevented them from being discharged.

This is why we strongly recommend working closely with the case management and discharge planning department. With experience, you will become more comfortable with knowing when a review should be a priority and when they can wait a day or two. This is a skill that you will learn.

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.