Administrative Memos

200104

FROM: Theodore O. Will, Chief Executive Officer
DATE: Mar 29, 2001
SUBJECT: DRG 416 (Septicemia, age gretaer than 17) Aggregate Data Report
IPRO CONTACTS:

Kathy Terry, Ph.D., Director, Data Analysis & Evaluation, Ext. 261 and Paula Monetti, Sr. Director, Program Integrity, Ext. 261

Enclosed please find a copy of IPRO's DRG 416 Aggregate Data Report. This report describes the findings of our DRG 416 PEPP project, based upon validation of a random sample of 400 medical records.

This DRG was selected by IPRO as a PEPP project because analysis showed DRG 416 (Septicemia, Age Greater than 17) to be among the top twenty (20) DRGs billed in the 1998 New York State (NYS) Medicare claims data. In addition, the Department of Health and Human Services, Office of the Inspector General (HHS/OIG) identified DRG 416 as a DRG at great risk for upcoding. Moreover, the March, 1999 OIG Report on Medicare Payments for Septicemia for fiscal years 1993 to 1996 reported atypically high billings for DRG 416 nationally.

There were no outlier patterns discerned in the 1998 NYS Medicare claims data based on stratification by hospital and peer group. Therefore, a total of 400 cases were randomly selected from all NYS DRG 416 Medicare claims billed in 1998. It is significant to note that of the reviewed cases, 29% were found to be in error. Coding errors resulting in incorrect DRG assignments were identified in 23% of the cases. Six percent (6%) of the cases were technically denied due to hospital failure to submit the requested medical records and one case (.3%) was denied for insufficient documentation to justify the necessity of the admission. Although case specific findings for all denied cases have been previously sent to the hospital under separate cover, a hospital-specific case list has been included with the enclosed report, if cases from your hospital were included in our study.

As a result of our findings, IPRO is developing DRG 416 training materials for hospital coders and physicians. In addition, we strongly encourage all Medicare Prospective Payment System (PPS) hospitals to assess their DRG 416 coding/billing practices to ensure that they are consistent with coding guidelines and that they accurately reflect the principal diagnosis as based on physician documentation in the medical record. To assist in this endeavor, IPRO has included a hospital-specific list of calendar year 2000 Medicare cases billed to DRG 416 with the enclosed report.

Should you have any questions regarding this report, please feel free to contact Dr. Kathy Terry (data questions) or Paula Monetti (coding/DRG issues).

REASSIGNED DRG CODES