Administrative Memos

200113

FROM: Theodore O. Will, Chief Executive Officer
DATE: Jul 05, 2001
SUBJECT: DRG 174/182 Aggregate Report
IPRO CONTACTS:

Kathy Terry, Ph.D., Sr. Director, Data Analysis & Evaluation, Ext. 261 and

Paula Monetti, Sr. Director, Program Integrity, Ext. 261

Enclosed please find a copy of IPRO's DRG 174/182 Aggregate Data Report. This report describes the findings of our DRG 174/182 PEPP project based upon validation of a targeted sample of 800 medical records. A substantial number of cases selected by IPRO for this study were found to be in error (12.9%). However, not all hospitals had cases selected for review. If cases from your hospital were included in our study, a hospital-specific report, including aggregate comparisons is included as Attachment II.

These two DRGs were selected as an IPRO DRG validation project for PEPP because of previous studies by the Department of Health and Human Services, Office of the Inspector General (DHHS/OIG) which identified certain DRG pairs with the potential for coding errors. One of these pairs is DRG 174/182 (Gastrointestinal Hemorrhage with Complication/Comorbidities vs. Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders Age >17 with Complication/Comorbidities). In New York State (NYS), each of these DRGs ranks within the top ten DRGs, based upon analysis of the discharge volumes by DRG for calendar years (CYs) 1998 and 1999. The CY 1999 NYS percent of DRG 174 to a combined DRG 174 and DRG 182 total was 51%, with DRG 182 at 49%. That is, the average hospital had approximately equal proportional discharges for the two DRGs.

All NYS Medicare inpatient Prospective Payment System (PPS) hospital claims with discharge dates in CY 1999 were included in IPRO's preliminary analyses to identify outliers. Providers were targeted as outliers if they had disproportionately high volume of discharges for either DRG 174 or 182. Cases were selected from all DRG 174 and 182 claims having discharges in CY 1999 for these select providers.

As noted above, the overall project error rate for the combined DRG 174/182 was 12.9%, with 9% of the errors attributed to coding errors, 2.4% to technical denials (hospital failure to submit the requested medical records), and 1.5% denied for insufficient documentation to justify admission necessity. DRG specific overall error rates for DRG 174 and 182 were 11% and 15%, respectively.

As a result of this project, IPRO suggests that hospitals implement the following actions:

Conduct ongoing internal auditing and monitoring to ensure the accuracy of DRG 174 and 182 assignments and the completeness of documentation.
Provide physician education on appropriate and timely medical record documentation to substantiate assignment of DRGs 174 and 182.
Provide continuing education sessions for coders on ICD-9-CM guidelines in the following areas:

Perforation vs hemorrhage
Occult bleeding vs gross hemorrhage
Types of GI problems
Sequencing of gastrointestinal hemorrhage
Use of complication and comorbidity codes
Assure complete and timely documentation of medical records such as transcribed discharge summary, history and physical, and operative procedure reports to support accurate assignment of codes and DRGs prior to submitting the claim.
Establish a code of conduct for coding processes. You may wish to use the AHIMA Code of Ethics and Standards of Ethical Coding as your guide.
Incorporate the above activities into your hospital's voluntary compliance plan.

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