Development of a hospital based menu driven clinician coding tool to implement quality reimbursement process in the U.S. – A cardiologist's diagnoses as an illustration
Affiliations: Opus College of Business, University of St. Thomas, Minneapolis, MN, USA
Correspondence:
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Address for correspondence: Sameer Kumar, Ph.D., Professor of Operations and Supply Chain Management and Qwest Endowed Chair in Global Communications and Technology Management, Opus College of Business, University of St. Thomas, Mail # TMH 343, 1000 LaSalle Avenue, Minneapolis, MN 55403-2005, USA. Tel.: 651 962 4350; E-mail: sameerkumar724@gmail.com.
Abstract: Aim:The purpose of this study is to review current in-hospital based coding techniques and explore various means by which clinicians and HIM (Healthcare Information Management) staff members (which include Coding Technologist or "Coders") miss potential technical fee reimbursement due to poor dictation and/or lack of knowledge of the newer MS-DRG coding system in the U.S. Methods:An analysis of the 2008 implemented MS-DRG reimbursement system was conducted to compare it to the older DRG system in use prior. With the help of a practicing Cardiologist, five randomly selected inpatient charts were reviewed to identify whether or not there was an opportunity to push deeper in to the patient diagnosis and treatment plan to determine if an opportunity existed to code each patient's diagnosis plan at a higher level due to poor documentation practices. Results:The review of five in-hospital patients charts seen by a Cardiologist, found that by correctly understanding the newer MS-DRG coding specifications and documenting patient diagnosis and comorbidities to appropriate reimbursement levels the hospital could have increased technical fee payments by about $50,000. Conclusions:By educating clinicians and HIM staff members to be rigorous in their dictation and interpretation of the patients MS-DRG diagnosis, comorbidities and treatment protocol, hospitals will be able to reclaim potentially millions of dollars annually. As more facilities adopt EMRs (electronic medical records), the introduction of "reminders" or drop down lists within an EMR could aid on the whole coding completeness, thereby increasing overall technical fee reimbursement levels while ensuring possibility of not overcharging accounts.
Keywords: MS-DRGs, reimbursement process, hospital payment, physician coding, informed decision making, best practices, medical diagnosis, centers for medicare and medicaid services (CMS), health insurance portability and accountability act (HIPPA)
