Complex DRG Review

Properly assigning DRGs is difficult, especially for highly complex cases. The shift to ICD-10, constraints on physician time and increasing demands on health information management (HIM) areas make it increasingly challenging for hospitals to select the appropriate codes and assign the DRGs that will provide hospitals with the reimbursement they are entitled to receive. The result is significantly lower reimbursement — an average of $6,400 per incorrectly assigned claim.

HPS Solution

HPS’s Complex DRG Review Solution (CDR) helps hospitals identify and re-file Medicare claims where the medical record clearly supports the assignment of a higher paying DRG. Using its expertise in data analytics and reimbursement, HPS identifies claims with a high probability of being undercoded. These claims are independently reviewed by medical coders. Claims that have a supportable case for a higher paying DRG assignment are re-filed in the Medicare DDE system.

CDR offers significant value to hospitals:

  • Complements existing coding review programs. Current coding review programs primarily focus on ensuring the accuracy of all claims using random samples. With CDR, HPS uses analytics to identify those claims with the highest likelihood of being undercoded and reviews only those claims. With a different focus, CDR provides complementary approach to reviewing claims.
  • Increases reimbursement without financial risk. CDR identifies claims where hospitals can appropriately receive higher reimbursement. HPS works with the hospital to re-file those claims in the Medicare DDE system within timely filing deadlines. HPS payment model is contingency based—so hospitals only pay if we find reimbursement.
  • Creates a partnership between HIM and Reimbursement. CDR creates a bridge between coding and reimbursement activities in a way that benefits both areas. The highly targeted analytical approach to identify undercoded claims, creates reimbursement opportunities while uncovering areas of training and education improvement to address root cause issues and provides a method to track coding improvement over time and monitor exceptions.