Room for improvement: gastrointestinal disorders and payment errors

Area of Science:

• Healthcare Management
• Medical Coding
• Patient Admission

Background:

• Physicians determine acute inpatient hospital treatment necessity and documentation for accurate diagnostic-related grouping (DRG) coding.
• Gastrointestinal (GI) disorders, specifically DRGs 174 and 182, are a national and New York State concern for admission necessity and DRG accuracy.
• A baseline review of 600 cases from 20 hospitals in FY 2006 identified significant admission and DRG coding errors.

Purpose of the Study:

• To evaluate the impact of physician education and documentation improvement on hospital admission necessity and DRG coding accuracy for GI disorders.
• To assess the effectiveness of targeted improvement plans in hospitals with high error rates.

Main Methods:

• A baseline audit of 600 cases from FY 2006 across 20 hospitals assessed admission necessity and DRG assignment for GI disorders.
• Hospitals exceeding a 10% error rate were mandated to implement improvement plans.
• A follow-up audit of 300 cases in FY 2007 re-evaluated error rates post-intervention.

Main Results:

• The aggregate error rate decreased from 13.3% at baseline to 8.0% upon re-measurement (P < 0.05).
• Admission denials decreased from 8.0% to 4.7%, primarily for DRG 182.
• DRG assignment errors decreased from 5.7% to 3.3%, primarily for DRG 174.
• Hospitals implementing formal improvement plans showed the most significant reduction in both admission and DRG errors.

Conclusions:

• Physician education emphasizing admission criteria and meticulous record documentation can effectively reduce inappropriate hospital admissions.
• Improving documentation accuracy enhances the precision of diagnostic-related grouping (DRG) assignment.
• Targeted quality improvement initiatives are crucial for addressing and rectifying errors in hospital admissions and coding.