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DRG Reviews, an essential component to any CMI or CDI program

Many hospitals utilize Case Mix Improvement (CMI) or Clinical Documentation Improvement (CDI) initiatives as a way to improve their revenue and coding accuracy.  Although these initiatives serve vital functions as part of a healthy revenue cycle, they don’t necessarily provide a thorough picture of potential coding compliance risks or potential missed revenue.  That’s why a robust DRG optimization review process is needed.  The retrospective nature of optimization reviews is a valuable tool to reduce compliance risk and revenue leakage for your facility. CMI and CDI initiatives provide great raw material for DRG reviews – these programs focus on clear, detailed documentation.  Improved documentation should result in optimal DRG assignment; however, this is surprisingly not always the case.

A benefit of CMI/CDI initiatives is the improved documentation these programs provide.  However, coders may not always have all of this information available to them when generating an initial DRG assignment.  Even with functional CMI and CDI programs at a hospital, retrospective optimization reviews often will still lead to more accurate DRG assignment and CMI points.  With more contracted payers moving to DRG rates, the pool of opportunity captured by these reviews has expanded well beyond Medicare and Medicaid fee for service.

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To provide a significant example of the continued value of DRG optimization reviews, CBIZ has recently identified a number of ventilator cases (DRG 871 case weight of 1.8564 to DRG 870 case weight of 6.2953) where we have been able to assign the correct and higher-paying, higher CMI/DRG.  We have found these cases incorrectly coded for a number of our clients; each one corrected resulted in an additional five-figure revenue bump for the hospital. These clients already had existing CMI, CDI or both types of programs prior to our retrospective reviews.  Not only were we able to help our clients gain additional, entitled revenue, but we also helped educate their coding staff so that they will have improved coding accuracy for these cases moving forward.

Retrospective DRG optimization reviews should be an essential part of a hospital’s revenue cycle. The reviews validate coding accuracy, and help to reduce compliance and lost revenue.  If you have questions regarding the information in this article or would like additional information on the services we offer, please click here to reach out to one of our representatives.


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