This monthly column will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.
By Wilbur Lo, MD, CDIP, CCA
AHIMA World Congress (AWC) is leading exciting initiatives outside of the US, and with its new AWC organizational membership program, AWC is dedicated to helping healthcare information professionals and their organizations achieve full potential and professional recognition in the Middle East, South East Asia, and European markets. Among the benefits included as part of the new AWC organizational membership program is the performance of a gap analysis by subject matter experts.
When the AWC team generated a comprehensive gap analysis report for its newest organizational member, Al Ain Hospital (AAH), a state-of-the-art 402-bed acute care and emergency hospital in the United Arab Emirates (UAE), opportunities were identified to increase the quality of clinical documentation, optimize patient care and safety, and streamline services. The analysis was based on thorough review and assessment of AAH sample records, analysis of case mix index (CMI), SOI/ROM, IR-DRG and LOS metrics, survey responses, and on-site meetings/interviews.
Clinical documentation improvement (CDI) holds much promise for healthcare providers beyond the United States, including exciting opportunities for AAH and other providers in the UAE related to International Refined Diagnosis-Related Groups. In order to appreciate how CDI could be applied in relation to IR-DRGs in the UAE, let’s first set the stage with a quick overview of the methodology of IR-DRGs, which are utilized by many countries.
Designed by 3M for international healthcare, IR-DRGs are versatile and code-independent, meaning that IR-DRGs provide the same results in classifying patients regardless of the type of coding systems used. This allows uniform comparisons across countries. In the UAE, IR-DRGs generated from ICD-10-CM diagnosis codes and CPT-4 procedure codes are used for ambulatory and inpatient facility reimbursement. ICD-10-PCS codes are not utilized to generate IR-DRGs in the UAE.
In Medicare Severity Diagnosis-Related Groups (MS-DRGs) and All Patient Refined Diagnosis-Related Groups (APR-DRGs), diagnoses form the primary axis of classification. But in IR-DRGs, procedures form the primary axis of classification.
IR-DRGs are comprised of seven digits: the first and second digits correspond to the Major Diagnostic Category (MDC); the third digit corresponds to the DRG type (e.g., Inpatient Procedure, Ambulatory Significant Procedure, Inpatient Medical); the fourth and fifth digits correspond to the DRG; the sixth digit corresponds to the severity of illness (SOI) subclass and the seventh digit (optional) corresponds to the risk of mortality (ROM) subclass. For instance, IR-DRG 014142 corresponds to MDC 01 “Diseases & Disorders of the Nervous System” (first and second digits “01”), Inpatient Medical DRG (third digit “4”), DRG 14 “Cerebrovascular Accident with Infarct” (fourth and fifth digits “14”) and SOI subclass 2 (sixth digit “2”).
IR-DRGs have similar grouper logic and algorithm as APR-DRGs, which are utilized in the United States. APR-DRGs have four subclasses [1 = “Minor”, 2 = “Moderate”, 3 = “Major” and 4 = “Extreme”] for severity of illness (SOI) and risk of mortality (ROM). In contrast, IR-DRGs have three subclasses [1 = “Minor”, 2 = “Moderate”, 3 = “Major”] for SOI and ROM. IR-DRG SOI subclasses 1, 2, and 3 correspond to “without CC,” “with CC,” and “with MCC” respectively, in which “CC” stands for “Complications and Comorbidities” and “MCC” stands for “Major Complications and Comorbidities.”
The APR-DRG grouper logic is complex. In general, two secondary diagnoses with SOI 4 or a combination of secondary diagnoses with SOI 3 and SOI 4 are required to generate composite APR-DRG SOI 4 (“Extreme”). There are multiple steps and caveats which determine the composite APR-DRG SOI, such as eliminating secondary diagnoses associated with the principal diagnosis and eliminating secondary diagnoses redundant with other secondary diagnoses.
In the grouper logic of IR-DRGs, the secondary diagnosis with the highest SOI score determines the composite IR-DRG SOI score. This precludes the need to capture multiple secondary diagnoses with SOI 3 in order to arrive at composite IR-DRG SOI 3. As such, the IR-DRG grouper logic leads to an exciting opportunity for CDI.
Here’s an example: Assume an inpatient case has composite IR-DRG SOI 1. If the CDI specialist generates a query to clarify documentation for a secondary diagnosis of severe malnutrition with SOI 3 and the physician agrees with the query, the composite IR-DRG SOI will shift from 1 to 3, with a corresponding increase in IR-DRG relative weight and length of stay (LOS). In this case, only 1 secondary diagnosis—severe malnutrition—is required to arrive at composite IR-DRG SOI 3.
So, how does this apply to Al Ain Hospital? Based on the gap analysis report, in a significant percentage of AAH sample records there were opportunities for CDI query generation with a positive impact on revenue and public reporting via increasing IR-DRG relative weights, increasing composite IR-DRG SOI/ROM scores, and/or decreasing LOS. Examples of query opportunities include:
- Query opportunity for record with MDC 01 (“Diseases & Disorders of the Nervous System”) to change working IR-DRG 014141 (inpatient medical IR-DRG) with relative weight 0.7984 and SOI 1 to target IR-DRG 014143 (inpatient medical IR-DRG) with relative weight 3.565 and SOI 3. The relative weight of the target IR-DRG is almost 4.5 times the relative weight of the working IR-DRG.
- Query opportunity for record with MDC 04 (“Diseases & Disorders of the Respiratory System”) to change working IR-DRG 044181 (inpatient medical IR-DRG; DRG “18”) with relative weight 0.3366 and SOI 1 to target IR-DRG 044112 (inpatient medical IR-DRG; DRG “11”) with relative weight 2.0041 and SOI 2. The relative weight of the target IR-DRG is almost 6 times the relative weight of the working IR-DRG.
Opportunities were also found to decrease the number of denials and decrease the number of appeals denied after submission, based on clinical validation and query generation to clarify diagnoses and procedures.
Based on comparisons of UAE hospitals with hospitals in the United States, AWC estimates that UAE hospitals can possibly generate between $4 million and $7.5 million in additional revenue each year once a CDI program is implemented, streamlined and optimized. To read the Al Ain Hospital case study and other case studies from AWC, click here: https://www.awc.world/awc-om-case-studies/.
The AWC Organizational Membership applies AHIMA’s 90-plus years of expertise to provide organizations with gap analysis by subject matter experts, best practices implementation, staff training, market recognition, and AHIMA’s organizational support. For more information, visit https://www.awc.world/org-member/.