Review & Validation of Diagnosis Related Groups (DRGs) To Optimize Reimbursement and Avoid Burnout
Written by: Makema Massey, BSHIM, RHIT, CCS, COCAS, CPC, CPC-I, CPMA
This article is for inpatient coder NERDS and provides a practical approach from one of our AIHC inpatient coding nerds (rather experts) addressing inpatient diagnosis related groups, or DRGs, reimbursement related to hospital Medicare billing.
Feeling bored with payment classification, continuing education webinars, and submitting claims with coding and billing errors?
Working in health care reimbursement is challenging. Repetition can lead to rote behavior which, in turn, can lead to mistakes. Your employer is counting on your highest level of performance, so it is important to learn how to deal with this issue effectively. I’d like to share what works for me in hope that it may help with your path to improved performance.
I had dealt with this feeling of boredom for a while, it seemed useless, and I found myself wondering if there was ever an actual algorithm to making sure that claims were submitted “correctly.” I found myself constantly searching for ways to become fired up again about correct reimbursement to ultimately receive the current and most optimal reimbursement available.
1. Get out of the “rut” - do something different
Initially, coding, billing, submitting claims, and auditing is satisfying and fun! But doing the same thing over and over will eventually lead to burn out. Sometimes you can get in a rut in the processes of coding and billing and become “computerized” or “mechanical” in your approach. It just seems to have been a purpose that got lost somewhere along with Father Time. Rather than giving up or looking for a new career, find ways to spice it up! Take a deeper dive into what you are doing – such as:
- Reading the Centers for Medicare and Medicaid Services’ (CMS) Quality Improvement Organization Manual, Chapter 4 - Case Review document on DRG Validation Review. Here you will find effective and implementation dates, the purpose behind review, responsibilities, and rules to guide you.
The objective of DRG validation is to ensure that diagnostic and procedural information as well as the discharge status of the patient, as coded and described by the hospital on its claim, matches both the attending physician’s description and the information clearly documented in the patient’s medical record. You don’t say? Of course, we knew that. But wait, there is more.
2. Remind yourself of your objectives
How many times have you “zoned out” into space out of sheer boredom? I sure know that I have done this plenty of times. Rather than quit, always remember why you are doing this.
Improve how you query providers. Examine your approach, professional judgement and discretion related to information contained on the physician’s query form along with the rest of the patient’s medical record.
- If it is leading in nature or if it introduces new information, it is up to you to identify this and either follow your processes to fix the issue internally or report the issue otherwise.
- You are trained and experienced in coding to perform DRG validation functions in order to verify the accuracy of the facility’s coding of diagnoses and procedures that affect the DRG. Verify the hospital’s coding in comparison to the coding principles that you have the ability to find in the current ICD Coding Guidelines.
3. Be sure you have on the correct uniform – and I’m not talking about your jeans
Sometimes, the right outfit makes you feel great. With that in mind, be sure to be equipped with the Uniform Hospital Discharge Data Set (UHDDS) to perform great! Having the right tools makes a world of difference in validating diagnoses and, moreover, procedures.
The UHDDS guidelines are used by facilities to ensure that reporting of inpatient data elements is standardized. The Uniform Hospital Discharge Data Set specifies that all significant procedures are to be properly reported. These are procedures that are surgical in nature, have a procedural risk, anesthetic risk, and/or require specialized training.
Remember, you only have the minimum core requirements of data with the UHDDS on hospital discharges and ICD-10-PCS procedural coding guidelines that go beyond the scope of the UHDDS are still required. You should also review HACS (Hospital Acquired Conditions). Visit the CMS ICD-10 HAC List webpage.
4. Take short, frequent breaks
Sometimes, burnout happens because our brains are telling us to take a natural break. It may be time to do nothing and relax….which means time away from screens (including your phone).
Spending long hours staring at a screen definitely takes a toll on your body, especially your eyes. Excessive screen time not only strains your eyes and leaves them feeling dry, but can also lead to retina damage and blurred vision. The amount of screen time you clock has a direct impact on how much sleep you are getting, given that the blue light emitted from digital screens interferes with the production of the sleep hormone melatonin in your body. I suggest reading more on this topic from Scripps and remember these tips:
- While working on a computer, look away and at a distant object for about 20 seconds every 20 minutes — set a reminder if necessary
- Take a quick standing stretch break every hour
- Learn a few “chair yoga” stretches to keep muscles loose
- Pay attention to your posture
- Don’t eat in front of a screen
- Avoid backlit screens for an hour before bed
- Note how long you spend on electronic devices and replace some of that with physical activity and social interaction
After a break you can now come back and take a fresh look at your coding, procedural facility specific, UHDDS, CMS, and other helpful guidances to ensure accuracy.
5. Focus! Accuracy is key and hyper-focus is required for your job!
Reduce wasted time by focusing on the principal diagnosis, any major comorbid conditions and complications, and surgical procedures. The coder is not required to add additional diagnoses or procedures on a claim, unless of course they affect the DRG.
Focus: Is the principal diagnosis the one in the medical record that, after study, is determined to have occasioned the patient’s admission to the hospital?
Focus: Are there other diagnoses that have no bearing on the current hospital stay? Delete them!
Focus: Are all reported procedures that affect the DRG on the claim? If additional procedures can be reported, first make sure that they affect the DRG.
Great you are focused! Now finish strong!
Follow through with making sure you verify the patients discharge status, age, as well as their sex as these factors are verified by the MAC prior to your validation and most importantly, no effect on the DRG, no matter!
Are you charged with producing information for your CFO related to Medicare Cost Reports? Another way to learn more about the financial aspects of institutional finances is to attend the next Medicare Cost Report training camp! Locate the next camp date and location. If cost reporting is not part of your job, consider learning more about becoming a Certified Healthcare Auditor.
- “The Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements.” Federal Register 50, no. 147. July 1985.
- Centers for Medicare and Medicaid Services. (2014, October 10). CMS Manual System. Centers for Medicare and Medicaid Services. Retrieved November 29, 2021, from https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R18QIO.pdf