Health Information Management

Q&A: DRG, CC, MCC target items for CDI analysis

CDI Strategies, April 1, 2010

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Q: As manager of data integrity I oversee my facility’s CDI program. Can you recommend specifically what MS-DRGs are best to review and track or what CCs should we track? 

A: I would review all admissions (possibly excluding moms/babies) and all payers. This shows that your facility’s program is compliance-focused rather than revenue-focused (an important distinction to outside auditors).   

Identify your facility’s top 25 DRGs and pay special attention to moving any symptom DRGs such as chest pain, back pain, syncope, dizziness, abdominal pain, etc., out of that list. Doing so addresses several issues. It removes the low-weighted cases from your overall CMI and identifies those cases inappropriate for inpatient status.   
From an internal auditing perspective, I would also develop a report that identifies all the RAC target DRGs and abstract those records to validate the DRG assignments, either prior to or after billing. An additional recommendation is to make sure that you are validating the DRG for every case with only one MCC or CC, as many RACs appear to be targeting these. This should be a pre-bill process. 
Some MCCs and CCs to target include:
  • acute renal failure
  • encephalopathy
  • acute blood loss anemia
  • atrial flutter
  • malnutrition
These are always query opportunities but with the RACs it’s important to make sure that the record clinically supports these conditions. 
Editor’s Note: Lynne Spryszak, RN, CCDS, CPC-A, CDI education director for HCPro Inc., in Marblehead, MA, answered this question.

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