APR DRG’S & CLINICAL VALIDATION Dawn Smith, BS, RHIT

OCTOBER 1, 2015 A WALK DOWN MEMORY LANE

2 BIG changes in one

Why is this important? APR-DRG grouper, version 30 The 3M All-Patient Refined (APR)-DRG grouper, version 30, is effective for inpatient stays with discharge dates on or after October 1, 2015. See IHCP Provider Bulletin BT201559 for related information. Why is this important?

All Patients Refined Diagnosis Related Groups (APR DRG) is a classification system that classifies patients according to their reason of admission, severity of illness and risk of mortality. What is an APR DRG?

“….our primary focus in maintaining the CMS DRG’s is to serve the Medicare population. We do not have the data or the expertise to maintain the DRGs in clinical area’s that are not relevant to the Medicare population. We do not have the expertise to maintain the CMS DRGs for newborns, pediatric, and maternity patients” Federal Register April 13. 2007 Why do we need it?

APR-DRGs vs. MS-DRGs APR-DRG address these deficiencies All APR DRGs have 4 severity levels Patient age is used in severity leveling APR-DRGs vs. MS-DRGs

The APR DRG system is applicable to a broader spectrum of the population than DRGs. DRGs show severity of illness when impacted by a condition considered a “cc” or “mcc” or a procedure. This is a predefined list developed and maintained by CMS. APR DRGs define risk (severity of illness) looking to additional indicators to determine complexity – age, diagnosis, procedure, discharge disposition. Is it better?

They paint a better picture of the patient APR-DRGs are a clinical, rather than statistical model. APR-DRGs expand upon DRGs by also assigning to each case a severity of illness (SOI) subclass and risk of mortality (ROM) subclass. Severity of Illness: the extent of physiologic decomposition or organ system loss of function Risk of Mortality: the likelihood of dying They paint a better picture of the patient

APR-DRG Assignment, Two Distinct Clinical-Based StepsA patient is first assigned to a base APR-DRG (e.g.: APR 139, Other Pneumonia) The patient is then separately assigned two distinct subclasses: severity of illness and risk of mortality. Each subclass has four possible assignment levels: 1 = Minor 3 = Major 2 = Moderate 4 = Extreme How does it work?

Can we optimize payment? The success of APR-DRGs ultimately depends on: Complete and accurate coding Complete and accurate documentation *Clinical specificity = coding specificity Can we optimize payment?

APR DRG NAME WHT ALOS 47.1 Transient Ischemia 0.5465 1.9 47.2 0.7202 2.4 47.3 0.887 2.9 47.4 1.2507 6 In this example adding a secondary diagnosis of “aphasia” we can move from a SOI of 1 to a 2.

Not just for reimbursement Quality Severity adjusted LOS Bundled payment risk adjustment score Risk adjusted Mortality Helps even the playing field for those doctors who keep saying “my patients are sicker so they stay longer” Not just for reimbursement

As with all opportunity there is risk… Clinical Validation

“Clinical validation is an additional process that may be performed along with DRG validation. Clinical validation involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented in the medical record. Taking Coding to the Next Level through Clinical Validation Article citation: AHIMA Work Group. "Taking Coding to the Next Level through Clinical Validation" Journal of AHIMA 85, no.1 (January 2014): web extra.

The Centers for Medicare and Medicaid Services (CMS) Recovery Audit Contractor (RAC) Scope of Work 2013 includes the following statement: “Clinical validation is an additional process that may be performed along with DRG validation. Clinical validation involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented in the medical record. Recovery Auditor clinicians shall review any information necessary to make a prepayment or post-payment claim determination. Clinical validation is performed by a clinician (RN, CMD or therapist). Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder. This type of review can only be performed by a clinician or maybe performed by a clinician with approved coding credentials.”1

Clinical validation means that diagnoses documented in a patient's record must be substantiated by clinical criteria generally accepted by the medical community. Generally accepted clinical criteria typically come from authoritative professional guidelines, consensus, or evidence-based sources. So what’s the dilemma?

They get to pick

Examples of what we are seeing Sepsis Acute Respiratory Failure Acute Kidney Injury Malnutrition Obesity with BMI > 39 Examples of what we are seeing

First – look for the truth – are doctors “over diagnosing” If not…. CHALLENGE APPEAL APPEAL APPEAL Develop protocols and treatment plans to support the clinical diagnosis. Start at the point of entry – ED or physician office. Query – but focus on the clinical indicators for the diagnosis based on a diagnostic standard. Educate physicians – our enemies are copy/paste, templates, no plan documented, why do they think the patient has the dx….. Include nursing, respiratory therapy, pharmacy, physical therapy. What can we do?

Educate yourself at every opportunity. Understand the changes we face. Get at the table – hospital and physician leaders need to understand and we are uniquely positioned to educate them on the impact to the organization. Support consistent and complete documentation by all the disciplines who provide care. Understand your EMR and the tools to improve documentation. Where do we go from here?