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.

"Oftentimes, a diagnosis may appear on the discharge summary that may not have been addressed in the medical record (pending test results, etc)," she said. "Best practice is to wait on the complete medical record since rebilling could result in a higher-weighted DRG that will automatically be reviewed by the QIO (quality improvement organization)."

"If internal financial policies lessen their bill hold timeliness then the discharge summary could be available and reviewed by a coding quality coordinator to ensure coding compliance," she said.

When coding claims, if there is conflicting or contradictory information in the record, a coder should query the attending physician to clarify the correct principal and secondary diagnoses, according to the article.

In addition, CMS cites Coding Clinic, First Quarter 2004: "If there is conflicting physician documentation and the coder fails to query the attending physician to resolve the conflict, hospitals are encouraged to code the attending physician's version, but that the failure of the attending physician to mention a consultant's diagnosis is nota conflict."

In these situations, it is a more prudent move to query the physician concurrently, according to Elizabeth Lamkin, MHA,partner, PACE Healthcare Consulting, LLC.

"Accurate documentation begins with the proper review by case management and physician advisor to give guidance to the attending/admitting physician," she said. "I'd recommend a clinical documentation improvement specialist (CDIS) to then review the documentation concurrently and assist the physician in navigating the chart."
If the physician documentation missed a note from a consulting physician or someone in the therapy department, for example, the CDIS can notify and query the physician during the patient's stay for clarification, she said. "The result should be more accurate documentation, better coding in the health information management (HIM) department, and appropriate reimbursement and billing compliance."