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  • Alabama HIMA: Clinical Documentation Transformation

    April 14, 2016

  • Disclaimer

    • This material is designed and provided to communicate information about inpatient coding, clinical documentation, and/or compliance in an educational format and manner

    • The author is not providing or offering legal advice but, rather, practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality, and coding

    • Every reasonable effort has been taken to ensure the educational information provided is useful and accurate

    • Applying best practice solutions and achieving results will vary in each hospital/facility and clinical situation

    2

  • Discussion Topics

    • Evolution and Differences of DRG systems and the impact on clinical data

    • Overview of APR DRG Methodology

    • Public Reporting and Why it Matters

    • Collaborate and Build a Team

    3

  • Discussion Topics • Evolution and Differences of DRG systems and the impact on clinical data

    – History of DRGs – MS DRGs – APR DRGs

    • Medical Record is the core / foundation for clinical data management – RAC Audits – Compliance – Severity of Illness (SOI) and Risk of Mortality (ROM) – Profiling Hospitals and Physicians – Hospital Acquired Conditions

    • Public Reporting and Why it Matters – Healthgrades.com – Hospitalcompare.gov – Qualitycheck.org – Data.gov

    • Collaborate with Leadership to gain support for the CDI Program – Establish a Steering Committee – Establish an Operational Committee – Select a Physician Champion

    4

  • Brief History of DRGs

    5

    American Health Information Management Association. “Evolution of DRGs (updated).”

    Journal of AHIMA (Updated April 2010) Copyright ©2016 by the American Health

    Information Management Association. All rights reserved.

  • Medicare Severity (MS) DRGs

    • MS DRGs were implemented October 1, 2007 to better recognize severity of illness

    – The MS DRGs were a significant improvement but it does not account the actual complexity of the Medicare population

    • Does not capture multiple additional comorbidities or complications

    – MS DRGs have a three-tiered structure

    • MCC

    • CC

    • Without MCC/CC

    – In the public domain

    6

  • 3M™ APR DRGs: Beyond Resource Use

    Development of a new method and refinement to evaluate hospitals

    • Evaluate hospitals across an extensive range of outcome and resource measures

    • Evaluate variances in inpatient mortality rates

    • Implement and support of critical pathways

    • Identification of continuous quality improvement projects

    • The need for a system to accurately capture “Case Mix Complexity”

    7

  • 3M™ APR DRGs

    • Overview: – All Patient Refined Diagnostic Related Group

    – Developed by 3M • AP DRGs used initially as the base

    • Yale’s R DRGs incorporated

    • PM DRGs (pediatric modification) National Association of Children’s Hospitals and Related Institution were integrated

    – Much more clinically uniform and similar

    – Calculates a severity of illness (SOI)

    – Calculates a mortality risk (ROM)

    – Takes resource intensity into consideration • Captures differences in the patient’s complexity of illness

    8

  • 3M™ APR DRGs

    9

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  • Factors Used to Calculate 3M™ APR DRGs – Case Mix Complexity

    Factors used to

    Calculate APR DRGs

    Severity of illness

    Risk of mortality

    Prognosis

    Treatment difficulty

    Need for intervention

    Resource intensity

    10

  • National Depth of Coding Trends

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  • Definition of Severity

    • Severity of illness (SOI) is defined as the degree of physiological decomposition of body systems – What does this mean?

    • Severity describes how ill a patient is and what resources are required to treat a patient

    • Risk of mortality (ROM) is the likelihood of dying

    • Resource Intensity is the relative volume and types of diagnostic, therapeutic and bed services used in the management of a particular disease

    12

  • APR DRG Levels –

    13

    Benefits

     Adjust for SOI

     Reimburse appropriately

    25

    MDCs