CMS Discloses DRG Coding Vulnerabilities for Inpatient Hospitals

In an effort to provide helpful information to providers, CMS has released a special edition MedLearn Matters (MLN) article that disseminates diagnosis-related group (DRG) coding vulnerabilities for inpatient hospitals.

Recovery auditors review the entire medical record when performing DRG validation reviews, but oftentimes hospitals code the record prematurely, according to Donna Wilson RHIA, CCS, CCDS, senior director at Compliance Concepts, Inc. in Wexford, PA. 

"As we know, hospitals code and finalize the claim without the final discharge summary documentation, given the struggles in meeting bill hold deadlines imposed by financial deadlines," she said. "External auditors—such as the recovery audit contractors (RACs)—have access to the entire medical record, which includes the discharge summary."

This practice puts hospitals at risk since they are responsible for reporting codes that accurately reflect the patient's conditions and procedures, therefore hospitals increase their chances of errors or denials. The article points out, for example, that the emergency department report, history, and physical (H&P), and early progress notes may indicate the patient has one condition, but continuing workup and evaluation may determine something entirely different.

By having access to the complete medical record, more accurate codes can be assigned, since auditors will review data from the entire medical record.

While this may not come as ground-breaking news to many providers, it is still a trend that needs to be addressed in many hospitals, according to Wilson.