The DRG dilemma.

This approach is alien to the way physicians are taught to approach clinical problems. Furthermore, to concentrate 15,000 ICD codes and 7,000 CPT codes into 527 DRGs results in a lack of precision in accurately reflecting the severity of each case.

The DRG system is rule-based. The concepts of complexity, severity, complication or comorbid condition (CC) and case mix index are utilized. There are thousands of potential combinations for DRGs that can only be appropriately sorted by a computer. However, the critical choices must be made based upon the patient's medical record as documented by physicians.

Complexity is based upon the resources utilized in treating a case measured by the principal diagnosis or procedure, and a relative weight (RW) is pre-assigned. For example, a newborn has a relative weight of 0.1524 and a heart transplant has a relative weight of 20.2413.

Severity is measured by the secondary diagnoses (number and complexity up to 15 for a given case). The case mix index is measured by adding the relative weights of all the cases treated by a physician or a hospital divided by the total number of cases treated over a given period of time.

Each year on October 1 the relative weight for each DRG is recalculated for Medicare, based on the previous 12 months' data. This is obtained by adding the costs of treating all the cases in a given DRG in the preceding year and by dividing the number of cases in that DRG during the preceding year to obtain the average cost for the DRG translated in relative weights to the fourth digit.

Comorbidity is a condition that exists on admission and increases the length of stay one or more days in 75 percent of the cases. A complication is a condition that develops in the hospital and increases the length of stay one or more days in 75 percent of the cases.

The length of stay allowed by Medicare is based on the average length of stay for a patient with a DRG with a given severity and given comorbidities and complications during the preceding year.

Importance of understanding the DRG system

Using DRG databases, it is possible to compare resource utilization by physicians and hospitals within the constraints of the system. In addition, it is possible to determine expected mortality and morbidity rates. The large size of the Medicare database results in accurate information because of regression to the mean.

The medical record coding staff can only use physician documentation for selecting the DRG for a case. Because of poor documentation in the clinical record, many properly treated cases are coded as less complex and less severe than they actually are. This introduces a significant error in many physician and hospital profiles.

There is a disparity between the proper care actually delivered and the morbidity, mortality and resource usage expected for the reported DRG that is of lesser complexity and severity.

As a result, some physicians and hospitals that are effectively treating patients are misrepresented by the data they generate. They are considered inappropriate utilizers of resources because of low severity levels resulting in high utilization of resources and high mortality and morbidity rates.

It is important to improve the accuracy of the information submitted to the data banks so that correct decisions are made about compliance, reimbursement, pay-for-performance and managed care contracting.

Information in the Medicare data bank is a matter of public record. There are companies that refine and sell these data. With the movement toward the release of physician-specific and hospital-specific information, it is vitally important to ensure that the information is accurate.

Improving data

The data from each encounter a physician has each day with any patient (private pay, managed care, insurance, Medicaid or Medicare) are placed in the Centers for Medicare and Medicaid Services (CMS) databank in Baltimore, Md., under the uniform physician's identification number (UPIN) at billing.

The data allow comparison of clinical efficiency, severity and complexity by ICD 9 codes, CPT codes for diagnoses and procedures, length of stay, resources utilized (cost per discharge) and morbidity and mortality rates.

As the severity and complexity of a case are accurately represented, the resources to care for that case and the length of stay (LOS) are properly accounted for in each group. If documentation does not reflect the severity and complexly correctly and completely, resources used are higher than the average allowed for that case.

This makes the physician appear to be inefficient in appropriately managing a case where the actual data documented reflect that the patient is not severely ill.

This raises the contradiction that the physician is billing for a high-level evaluation and management (E/M) code (and possibly giving a high level of care) but documenting only a low level of care.

Since medical record audits are now becoming more routine, it is essential that physicians become aware of the data accumulated daily in their practices. When audits are done in the hospital or office setting the following simple questions must be answered:

* What did the physician do (CPT or ICD 9 CM procedure code)?

* Why did the physician do it (ICD 9 CM code)?

* Was the service reasonable and necessary?

* Is the medical record legible?

Resolving the DRG dilemma

Physicians must learn a new language essential for documenting clinical efficiency that reflects the service actually provided the patient, and to do so they need assistance with education, educated case managers and educated coders.

In addition, a worksheet (Figure 1) is attached to each record, but not part of the medical record, and is an important tool for teaching each specialty group.

Based upon limited documentation the medical record coder is required to list DRG 143, atypical chest pain with an average E & M level of 1, RW of 0.5391 and a LOS of 1.7 days as the principal diagnosis.

Review of the worksheet shortly after admission--together with the orders, X-rays and lab work--suggest that the case being treated is DRG 127, heart failure and shock with an E & M level of 3, RW of 1.0037 and LOS of 4.1 days. This can then be appropriately documented in the medical record resulting in an improved E & M level, relative weight and length of stay.

In conjunction with physician executives, a concerted program of education including presentations to medical staff departments, record review and individual physician profile review is instituted.

Regular meetings with physicians, case managers and medical record personnel are held. These are combined with systematic data quality audit of medical records to reinforce the educational program. In addition, physician-specific and department-specific profiles are shared with appropriate individuals.

The importance of a physician's profile is emphasized in all meetings. In our experience, after formal presentations and individual conferences with key physicians selected by the physician executive, a few physicians grasp the significance of complete documentation for an accurate representation of their clinical management.

This number increases with time and a core of knowledgeable members of the medical staff is developed who can work with the hospital's medical executives to continually reinforce and expand the program.

DRG worksheets contain information about possible DRGs to be considered if there is appropriate documentation in the record that more accurately represents the clinical condition being treated.

This enables productive collaboration between physicians and case managers. Also information about the evaluation and management level, relative weight and allowed length of stay is included. Retain the worksheets to be used in audits.

Through education of physicians, case managers and medical record personnel, together with record review and information sharing, documentation in the medical record is improved. DRG accuracy is increased and steps toward resolving the DRG dilemma can be made. The complexity and severity of the case is accurately represented so that the use of resources and length of stay are appropriate for the case as actually treated.

FIGURE 1 DRG Worksheet

143 DRG Worksheet           Physician            Date
Patient                     Address

Initial    Days for Subsequent Visits     day 1        day 2     day 3
           Physician E/M Level

Discharge  Days for Subsequent Visits     day 4        day 5     day 6
           Physician E/M Level
DRG        Description                    Avg. E/M     RW        LOS
85         Pleural Effusion w CC (Bill)   3            1.2145    4.8
144        Cardiomyopathy Pericarditis    3            1.1992    3.8
           Hypotension w CC (Bill)
89         Pneumonia strep viral or       3            1.0420    4.8
           Pleurisy w CC (Bill)
127        CHF Heart Failure Rt Lt        3            1.0039    4.1
           or Shock (Bill)
88         COPD Ch obs Asth or            2            0.9028    4.1
           Ch Bronchitis (Ch P)
138        Card Arrhy Block Conduct       2            0.8274    3.1
           Disor w CC (Bill)
182        Esoph Gastroenteritis w CC     2            0.7986    3.3
           (Ch Princ)
132        Cor Atherosclerosis w CC       1            0.6564    2.3
           (Ch Princ)
140        Angina Unstable Ac cor insuff  1            0.5382    2.1
           Stab (Ch Princ)
143        Atypical Chest Pain (Cause)    1            0.5391    1.7
           (Ch Princ)

Please Document
41071 Acute MI / 4280 CHF / 4271 Vent tachy / 78550 Shock / 4589
Hypotension / 4239 Pericarditis / 4254 Prim Cardiomyopathy
5057 Aspiration bronchitis / 4919 Chronic / 5110 Pleurisy / 5180
Atelectasis / 515 Pul fibrosis / 4928 Emphysema bronchitis
496 COPD / 5119 Pleural effusion / 51881 Resp failure / 49320 Ch obs
asthma / 51882 Respiratory Insufficiency
Acute dilated stomach / Acidosis / Alcohol abuse / Anemia acute blood
loss / Angina stable / Alkalosis / Anemia chronic blood loss
Aortic valve disorder / Aspiration bronchitis / Atony of bladder /
Atrial fibrillation / A-V block 2nd degree/ Bacteremia / Bilateral BBB.
CHF compensated / Decubitus ulcer / Dehydration (vol dep) / Diabetes
uncontrolled / Drug abuse / Electrolyte imbalance
Fluid overload / Hallucination / Hematemesis / Hematuria / Hemoptysis /
Hypovolemia / Malnutrition / Volume depletion
Intestinal impaction / Mitral valve prolapse / Paralytic ileus /
Pleurisy / Post OP inf / Thrush / Urinary tract infection

The Following MEDICARE CCs Are Most Commonly Missed
Initial Vis: History/Physical Documented Items; (Level 1, 20-30), (Level
2, 30-40), (Level 3, 40-50)
Subsequent: SOAP Notes; Documented Items; (Level 1, 5-10), (Level 2,
10-20), (Level 3,20-30)
New Office & ED: (Level 1,5-10), (Level 2,10-20), (Level 3,20-30),
(Level 4,30-40), (Level 5,40-50)
Established: Docu Items; (Level 1,3-5), (Level 2,5-10), (Level 3,10-15),
(Level, 4,15-20), (Level 5,20-30)

Document Criteria for Severity of Illness & Intensity of Service
Temp>102 IV Med Hemoptysis Resp Rate > 30 pH <7.35 or >7.45 po2 < 60
pCO2 > 50
Vital signs ch Acute SOB Narcotics 3X daily Obstructive breathing Ac
Pain on Deep inspiration WBC> 15,000 Airway care Comatose Infection
Seizure + X-ray
O2 stand-by Vent Monitor Surg or Proc
Add all Diag (Up to 15) & Subclasses; Diabetes uncontrolled, neuropathy,
PVD, etc.
Add Chronic Obstructive Asthma if continuous treatment & steroids,
repeat Adm
Add a Diag for each Ordered (IV fluids, lasix, insulin, digoxin,
antibiotics, NTG, steroids etc.)
Document in Progress Notes a Diagnosis for all abnormal tests

Copyright [c] Hospital Reimbursement Systems, Inc. All rights reserved.

Treatment Considerations
* Stabbing or burning, variable in position & intensity
* Unrelated to physical exertion, unresponsive to NTG
* Neuromuscular, pleurisy or GI
* SOB, weakness & fatigue, check cardiovascular output
* Na & K supplement, manage anemia, arrhythmia's, hypoglycemia, drug
  toxic, elect
* Antiplatelet drugs, Aspirin, ticlopidine 250 mg bid, clopidogrel 75 mg
  d
* Diet: Fruits, vegetables (fiber, proteins) 5 servings/d
* Exercise: Frequency 2 X wk, Intensity HR > 100, Duration 20-30 min
* Method 8-12 repetition 8-10 muscle groups

DRG 140 Angina Pectoris
A clinical syndrome due to myocardial ischemia characterized by episodes
of precordial discomfort or pressure, typically precipitated by exertion
and relieved by rest or sublingual nitroglycerin. It may also be
expressed as nausea, vomiting, epigastric pain, diaphoresis, or cardiac
arrhythmias.
Treatment: Nitroglycerin, long acting nitrites, B-adrenergic blocking
agents, ca antagonists, antiplatelet drugs, bypass surgery and
angioplasty.
DRG 132 Atherosclerosis of the coronary arteries cause ischemia and
angina in most cases.
DRG 138 Cardiac Arrhythmias
Angina frequently precipitates ventricular arrhythmias or ventricular
tachycardia.
DRG 127 Congestive Heart Failure
CHF frequently is precipitated by an acute anginal attack and if present
on admission and treated (such as Lasix or Lanoxin) may be sequenced
first.
DRG 182 Look for GI etiology of "anginal" chest pain such as
esophagitis, hiatal hernia with reflux, dyspepsia and peptic ulcer
disease.
DRG 99 Look for chest wall pain with tenderness to palpation of the
chest wall and use of non-steroidal anti-inflammatory medications such
as Indocin, aspirin. Musculoskeletal chest pain
DRG 90 Pleuritic chest pain with pain on deep inspiration or cough.
DRG 395 Red Blood Cell Disorders. Anemia with Hct < 27 or treated as
cause of angina.
DRG 121 Suspected Acute subendocardial or Non-Q wave infarction.
Increase in cardiac enzymes, supportive EKG findings of S-T wave changes
& Inverted T wave.
DRG 174 Look for chest pain due to GI bleeding with hypotension, anemia,
+stool and tachy.
DRG 94 Pneumothorax may cause chest pain, documentation and treatment.
DRG 101 Tietze's syndrome may cause chest pain and is characterized by
tenderness to palpation of the chondrocostal chest wall junction. Rib
strain or rib cage strain may also cause chest pain.
Treatment: NSAID such as Indocin or local injection of cortisone for
Tietze's Syndrome
DRG 204 Disorders of the Pancreas or pancreatitis may cause anginal-like
pain.
DRG 207 Disorders of the Biliary as cholecystitis may cause anginal-like
pain.
DRG 78 Pulmonary Embolism may cause chest pain. Look for thrombosis and
test, lung scan ABGs and treatment with anticoagulants.
DRG 83 Look for silent but recent traumatic injury to the chest with
tenderness to palpation.
DRG 144 Look for pericarditis, post cardiac surgery complications and
post MI complications.
78650   Chest pain unsp           V717 Observe susp Cardiovas dis
78659   Chest pain oth sp         78651 Precordial pain
LOOK FOR: anemia, pancytopenia, aplastic anemia, dehydration,
malnutrition, Agranulocytosis, thrombocytopenia, bleeding, obstruction,
resp comp, aspiration, complex pneumonia, (gram-neg., staph, etc.)
aspiration pneumonia, resp failure, mets

Worksheet Summary:
Rows 1 & 2  Patient demographics interfaced with admission software
Rows 3-6    Physician's Evaluation and Management (E/M) levels from
            admission to discharge
Rows 7-17   DRG options with pertinent data to improve the medical
            record Column 1 DRGs, Column 2 Description of diagnoses
            group, Column 3 Average physician E/M severity level, Column
            4 Relative weights (*hospital base pay = hospital payment),
            Column 5, mean length of stay (LOS) for all USA hospital
            discharges' in that DRG.
Rows 18     Blank space for case manager notes to the physician on
            findings not documented
Rows 19     Limited list of possible comorbid and complicating
            conditions (CCs)
Rows 20     If clicked, 250 commonly missed comorbid and complicating
            conditions (CCs) appear for documentation if present
Rows 21-24  Describes necessary documentation needed for each of the
            E/M level on a New, Established, Initial and Subsequent
            patient visit
Rows 25-29  Minimal criteria for admission and severity of illness
Rows 30+    Clinical information that is closely related to patient's
            admission and continuing care that should be clearly
            documented if present

By C.C. Moreland, MD and David Bloom, MD, CPE, FACPE

C.C. Moreland, MD, is the founder and president of The Moreland Group, Inc., formally known as Hospital Reimbursement Systems, Inc., in Monroe, Ga.. He can be reached at 800-343-1209 or [e-mail].

[ILLUSTRATION OMITTED]

David M. Bloom, MD, CPE, FACPE, is a consultant with The Moreland Group, Inc. He can be reached at 941-377-1445 or [e-mail].

[ILLUSTRATION OMITTED]

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Government agencies and insurance companies are increasingly utilizing diagnosis-related group databases to evaluate physician and hospital practices. However, the average practicing physician and physician executive has little or no knowledge of his own or his institution's profile.