Catalog Number : cra1234
Title : Conducting DRG Audits
Speaker : Duane Abbey

Duration : 120 minutes

Webplay Recording Date : 5-3-2006
Webplay Price : $ 225 for two weeks viewing

Webinar Overview - General

Changes in DRG methodology, coupled with the shortage of experienced and qualified coders, can potentially lead to incorrect DRG assignment. Payers that take a proactive approach to claim overpayments typically use a DRG Audit to identify suspect DRGs and focus their revenue recovery efforts where they’ll realize the highest return.

Dr. Duane Abbey will demonstrate how a structured coding and billing audit validation program will assist your facility in preventing development of patterns of noncompliance, which potentially result in OIG fraud and abuse investigations, and/or loss of significant revenue.

Learning Objectives Include:

To review the DRG payment system including the new severity refinement.
To understand how the DRG grouping logic determines payment for inpatient services.
To discuss the critical aspects of compliance issues surrounding DRGs and related case rate payment systems.
To appreciate the significant of developing the correct principal diagnosis.
To understand the role of secondary diagnosis and procedure codes for proper DRG grouping through CCs and MCCs.
To understand the need to audit for special combinations of DRGs as identified by CMS, the OIG and other third-party payers.
To appreciate the need to audit for special features of DRGs including the Present on Admission (POA) indicator, discharge status, and interfaces to various outpatient services.
To review the process of conducting a DRG audit, the purpose, process and outcomes that can be expected.

The following are only a few of the topics to be discussed:

I. Overview of DRGs and Case-Rate Systems
   a. Coding Systems
   b. Overall Grouping Process
   c. General Compliance Concerns
   d. Case Mix Index (CMI)
   e. New Severity Refinement - CCs and MCCs
II. Key Definitions and Concepts for DRGs
   a. Principal Diagnosis
   b. Secondary Diagnoses
   c. Primary and Secondary Procedures
   d. Complication or Comorbidity
   e. Major Complication or Comorbidity
III. Documentation for DRGs
   a. Documentation Process and Form
   b. Discharge Summaries
   c. Physician Queries
IV. Problem DRGs
   a. Special Pairs/Triples/Quadruples of DRGs
   b. Compliance Upcoding Concerns
V. Special Issues
   a. Transfer Rule
   b. DRG Pre-Admission Window
   c. Cost Outliers
   d. Observation Interface - Condition Code 44
   e. Concurrent Coding
   f. Utilization Review
VI. DRG Audit Process
   a. Selection of Cases
   b. Stratification
   c. Review Process
   d. Reports and Recommendations

Prerequisites for Participating: General knowledge of inpatient services and associated ICD-9-CM diagnosis and procedure coding.

Suggested Attendees: Inpatient Coding Personnel, Coding, Billing and Claims Transaction Personnel, Internal Auditing Personnel, Financial and Compliance Personnel, Physicians and Other Interested Personnel

Attendance Certificate: Upon attending this course you will receive a 2 Contact Hour Attendance Certificate. There is usually a reciprocal agreement between state associations to allow these to count for each state. If you have any questions, please ask your state association.

Refund Policy:

Full tuition is refunded immediately on request if the participant has not been sent the program materials and instructions. Once the instructions (including access codes) have been sent, a full refund will be issued only after the program runs and it is verified that the participant did not access the program.

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