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DRG Mismatch

DRG Mismatch: the buzz word for how well the Clinical Documentation Improvement department and the Inpatient Coding department are coming to the same conclusion on the appropriate codes applied to the medical record.

It has been discussed amongst many in the industry that an appropriate benchmark of program success is based on the percentage of final DRG cases that are matched by the two teams. But to date, I have been unable to find an industry standard benchmark and even a consensus as to the importance of it.

  • The first point around the subject is that (from experience) most standard programs have a 75% or higher match rate, but are unaware of their success rate, as it is the discussions and work that goes into the 25% or less of the cases that make it feel like a larger issue than it is.
  • The second point is that if captured and trended, there should be improvements seen if the process to address the mismatch is an educational one and not a punitive one.
  • Final point is that Inpatient Coding and CDI come at the chart at totally different time frames and many times, feel that they have different perspectives.

CDI is a concurrent process whereby the specialist looks at documentation as it is being produced with the intent of making sure the clinical picture is documented in the words that are needed by the coders in the final coding of the case to accurately reflect the true Severity of Illness (SOI), Risk of Mortality (ROM) and Utilization of Resources (appropriate DRG).

The coder is tasked with finding the words and then making sure the clinical picture supports them in order to apply codes that too will reflect the true SOI, ROM and DRG.

Putting in place a sound process of review of the mismatch cases, the reasons why and educational opportunities for both CDI staff and the coding team is an important step in the optimization of both quality scores and revenue for healthcare organizations in the future. Historically Coding and CDI have struggled with the development of positive discussions around these cases from an educational opportunity alone. Thus it is many times the bringing in of an outside impartial source to assist in the development of these processes and discussions that will ensure a more positive outcome. The long-term goal is that with time, the groups will see the educational advantage of these discussion and it can be maintained internally.