To better capture the increasing severity of illness observed among BWH inpatients, hospital management has been working with senior clinical leadership since last fall to implement a program with Arthur Anderson entitled “DRG Assurance.” The heart of this program for clinicians is the establishment of a new concurrent medical record review team based in Care Coordination, consisting of several experienced clinical nurses with training in coding regulations and guidelines. This team will be reviewing targeted inpatient records to assure that all patient comorbidities and associated treatments are adequately documented for proper assignment of severity of illness, according to HCFA’s rules and regulations.
The need for this sort of program was recognized after an on-site medical record audit in February 1999. This analysis revealed that both the average severity index and the expected risk of mortality for reviewed cases were significantly understated based on existing MD documentation in the progress notes, operative notes, and discharge summaries. Such under-documentation can have an effect on DRG assignments, and may ultimately lead to inadequate compensation for the level of services actually delivered. This is critically important as 58 percent of BWH’s annual discharges are reimbursed on a “prospective” DRG-based (case rate) system, including Medicare, Blue Cross, and HPHC. The potential financial impact from this program has been estimated at approximately $6 million in additional revenue per year.
The DRG Assurance Program introduction has involved comprehensive hands-on training for both the nurse reviewers and medical records coding staff in classroom settings as well as on inpatient units. Staff physicians have begun to receive brief didactic sessions describing the current BWH clinical “profiling” problem, the mechanics of how the concurrent review process will work, and how the program will benefit both hospital-wide and physician-specific profiling. These introductory sessions will continue throughout April at divisional and sectional meetings.
Please contact Michael Gustafson, MD (ext. 8894) or Andy Sussman, MD (ext. 6240) for more information.