Revenue Cycle

Understanding clinical documentation reconciliation

HIM Briefings, August 1, 2016

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Reconciliation is a noun meaning "the process of finding a way to make two different ideas, facts, etc. exist or be true at the same time." In the world of clinical documentation improvement (CDI), "reconciliation" typically refers to diagnosis-related group (DRG) reconciliation, which is the process of adjusting DRGs when those assigned by the CDI specialist do not match those assigned by the coder.

To understand why the reconciliation process occurs, you must understand the timing and assignment of DRGs by CDI and coders. CDI specialists (who are often clinicians rather than coders) may assign one or more DRGs during concurrent case review. After initially reviewing physician notes, tests, lab results, and other pertinent clinical documentation, the CDI specialist will assign an initial or working DRG. During the course of the patient stay, the CDI specialist may assign subsequent DRGs based on changes to the clinical documentation. These ­subsequent DRGs are often referred to as CDI DRGs, target DRGs, viable working DRGs, or query DRGs. When properly implemented, the concurrent review process results in a CDI DRG assignment that most accurately reflects the patient stay. The assignment of CDI DRGs is completed before discharge, while documentation is still subject to change. The last DRG recorded by the CDI specialist is typically used to calculate the financial impact of the CDI program for that case.

The assignment of the coder DRG is more straightforward. After discharge, and when all documentation has been completed, coders review the case and assign a final DRG.

Most CDI programs track the financial impact (both positive and negative) of their query efforts by quantifying the difference in relative weights between the working DRG and the CDI DRG. In order to calculate a financial impact, there must be at least one query, and the CDI DRG assignment must agree with the final DRG.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to HIM Briefings.

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