A New-and-Improved DRG Mismatch Process Has Positive Implications for Coders

New workflow manages DRG mismatches.

Last week on Talk Ten Tuesdays, Lidiya Ter-Markarova, CEO of Innova Revenue Group, discussed a new process that reduces the amount of time it takes coding and clinical documentation integrity (CDI) to reconcile diagnosis-related group (DRG) mismatches. Cutting out the back-and-forth practice of the coder justifying to CDI why their DRG differs has had a positive, advantageous impact on the coders and the coding team as a whole.

Coding is the lifeline of the revenue cycle, and having an efficient DRG reconciliation process in place is crucial for claims to get out the door in a timely fashion. The traditional DRG mismatch reconciliation process that many organizations have in place has not led to the best working relationship between coding and CDI.

The traditional process for the coder involves verifying that the DRG assigned by CDI matches what they assigned at the time of final-coding an account. If the DRGs do not match, the coder will re-review the record and the CDI specialist’s notes to see if there was something that they missed or could have coded differently.

One of the most common reasons for DRG mismatches is CDI assigning a different principal diagnosis than the coder. There are also other DRG mismatch reasons, such as a missed complication or comorbidity (CC) or major CC (MCC), an incorrect procedure code assigned, the wrong discharge disposition being selected, or an incorrect seventh character being added on an ICD-10 code.

Once the reason for the DRG mismatch is found, the coder notifies CDI and includes the reasons why they arrived at a certain DRG. The coder will reference any coding guidelines or official coding references, such as American Hospital Association’s (AHA’s) Coding Clinic, to justify the reason for their final assigned DRG. At times, CDI may not agree with the coder’s reasoning, and this starts the back-and-forth dialogue until a consensus is reached. If a consensus cannot be reached, the usual process is to involve a third party, such as the coding or CDI manager or the physician advisor, to be the tiebreaker. As you can see, this process can be quite cumbersome and time-consuming. The amount of research and emails sent between coding and CDI takes a big chunk out of their productive time.

Since we have implemented the new DRG mismatch workflow, the coder now codes the account, and if a DRG mismatch occurs, the account is routed to a DRG mismatch work queue, wherein the DRG mismatch auditor reviews and determines the correct DRG. The auditor keeps detailed notes of the most common DRG mismatches and provides education to the coders and CDI at their monthly huddle. The education provided to the coding and CDI teams focuses on things like coding guidelines, reviewing clinical criteria, hospital-acquired conditions (HACs) and patient safety indicators (PSIs), and coding difficult procedures as a team.

We even incorporated top DRG denials in these meetings.

The feedback we received from the coders and CDI was nothing but positive. Coders were being exposed to the clinical aspects of coding, and CDI was learning the coding guidelines. This new DRG mismatch workflow has significantly increased coder productivity, coder morale has improved, and the coding and CDI dynamic is more team-oriented, instead of being a coder versus CDI battle.

The tension between coding and CDI has been significantly reduced. This new process has given the coders time to focus on coding, so CDI can focus on making sure the documentation paints a clear clinical picture of the care provided to the patient.

Programming note: Listen to the live reporting by Patty Chua on this subject today on Talk Ten Tuesdays, 10 Eastern.


Patty Chua, RHIT, CCS, CCDS

Patty Chua, RHIT, CCS, CCDS, is the founder and COO for Innova Revenue Group. She has more than 20 years or experience in the HIM/CDI/coding industry and is one of the nation’s foremost experts in coding and clinical documentation integrity (CDI). She is proficient in all aspects of CDI, revenue optimization, inpatient and outpatient coding, auditing, charge capture, and regulatory compliance.

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