The Coder as the Last, Best Hope for the Right DRG

by Erica Remer, MD, FACEP, CCDS

If the story doesn’t make sense, there is probably something missing. There are a variety of reasons why the DRG might not tell the story of the patient encounter. Some of these include:

• Suboptimal medical care
• Confusing story because the provider wasn’t clear on what was going on
• No clear answer because the signs/symptoms resolved without a satisfying ultimate diagnosis
• Whack-a-mole medicine – the provider chases each abnormal test result and symptom without stepping back to see the big picture
• Clinician practicing bad medicine, often disregarding medical necessity

• Suboptimal documentation
• Provider practice of describing, instead of ascribing
• Providers being taught CDI “buzz words,” without understanding the goal is to accurately depict the encounter including conditions which make the course more complex or complicated
• Coding-clinical disconnects

• Missed CDI opportunities (CDIS is used for whoever is performing the CDI role)
• CDIS with limited repertoire of commonly missed CCs and MCCs without picking up on uncommon conditions which increase severity and complexity
• Auditor aversion where CDIS declines to query because she/he has been burned by denials
• Provider aversion where CDIS declines to query because she/he is intimidated by the provider, and has low expectations of getting the correct response
• Unrealistic productivity goals
• Over-reliance on Computer-Assisted CDI

• Suboptimal coding
• ICD-10-CM has A LOT of codes. Every day I find a new code that I never saw before! Can’t code it if you don’t know it exists and are not looking for it in the encoder or book.
• Only coding from limited parts of the record, like, “It has to be in the discharge summary” or just looking at the assessment or impression without reading the narrative
• Not reading the story to understand the big picture, especially if utilizing Computer-Assisted Coding
• Unrealistic productivity goals 

I just finished putting together the slide deck for my talk, CDI: The Coder as the Last, Best Hope for the Right DRG and I can’t wait for March 21st! I have some fascinating cases to go over with you, and some conditions which you might not always see. I can’t fix ALL of the reasons why the DRG goes awry, but let’s explore some together. Join me at the OHIMA 2018 Annual Meeting & Trade Show in Columbus in March.  Hope to see you there!

Dr. Erica Remer is scheduled to speak at the OHIMA 2018 Annual Meeting's Coding Day on Wednesday, March 21st at 12:45 PM.  If you are interested in hearing her presentation as well as many other fantastic speakers, register for the OHIMA Annual Meeting today!