Medical Record for DRG/CBG Coding Purpose dr.  Robertus  Arian  D.  Head  of  Emergency  Dept.  Panti  Rapih  Hospital  

http://www.jacksongeneral.com  

Topics

• Literature  Review  

• Medical  Record  Files  

• Problems  

• Fraud  

• Conclusion  

http://i.livescience.com  

Learning from Thailand (1) - Results • Hospital  providers  should  not  be  assumed  capable  of  producing  high  quality  DRG  codes,  especially  in  resource-­‐limited  settings.  • …  variation  in  hospital  coding  practices  in  an  under-­‐resourced  health  system  is  another  major  determinant  of  DRG  coding  quality.    •  It  was  not  fair  for  a  hospital  to  be  assumed  ‘capable’  of  producing  good  codes  without  qualified  physicians  and/or  coders.    • …  the  use  of  software,  number  of  medical  statisticians,  and  experience  of  physicians  seemed  to  be  the  most  important.    

Pongpirul  K,  Walker  DG,  Rahman  H,  Robinson  C;  DRG  coding  practice:  a  nationwide  hospital  survey  in  Thailand;  BMC  Health  Services  Research  2011,  11:290        

Learning from Thailand (2) –Hosp. Intention

•  FACTOR  1  –  Data  Quality    •  Audit  •  Improvement  

•  FACTOR  2  –  Coding  Practice  •  Physician  responsible  •  Incentive  /  punishment  •  Career  pathway  for  medical  statistician  

•  FACTOR  3  –  Reimbursement    •  DRG  seeker  software  •  Various  combinations  of  codes  entered  •  Swap  principal  and  secondary  diagnoses  

Pongpirul  K,  Walker  DG,  Rahman  H,  Robinson  C;  DRG  coding  practice:  a  nationwide  hospital  survey  in  Thailand;  BMC  Health  Services  Research  2011,  11:290        

http://images.amari.com  

Pongpirul  K,  Walker  DG,  Winch  PJ,  Robinson  C;  A  qualitative  study  of  DRG  coding  practice  in  hospitals  under  the  Thai  Universal  Coverage  Scheme  ;  BMC  Health  Services  Research  2011,  11:71        

Thailand vs Indonesia •  Discharge  Summarization.  Clinical  data  in  medical  records  are  used  to  fill  out  the  discharge  summary.  The  physician  responsible  for  the  patient  is  considered  the  best  person  for  this  task.    •  Completeness  Checking.  This  step  is  to  check  the  completeness  of  the  medical  record  and  discharge  summary.  Charts  with  incomplete  clinical  data  will  be  returned  to  the  responsible  physician  for  correction.    •  Diagnosis  and  Procedure  Coding.  The  hospital  coder  assigns  the  ICD-­‐10  code  and  ICD-­‐9-­‐CM.  Should  there  be  any  missing  or  questionable  information  in  the  discharge  summary  or  medical  record,  the  coder  will  inform  the  responsible  physician,  who  may  or  may  not  agree  to  revise.    •  Relative  Weight  Challenging.  •  Coding  Report.    

Pongpirul  K,  Walker  DG,  Winch  PJ,  Robinson  C;  A  qualitative  study  of  DRG  coding  practice  in  hospitals  under  the  Thai  Universal  Coverage  Scheme  ;  BMC  Health  Services  Research  2011,  11:71        

About Discharge Summary (1) •  “…  the  Medical  Records  are  not  documented  properly  in  the  university  hospital  where  the  Medical  Records  are  also  used  for  educational  purposes.”  (Pourasghar  et  al,  2008)  •  “Inadequacies  were  found  in  clinical  documentation,  especially  gross  underutilization  of  discharge  summary  forms.  Some  forms  were  properly  documented,  suggesting  that  hospital  healthcare  providers  possess  the  necessary  skills  for  quality  clinical  documentation  but  lack  the  will.”  (Adeleke  et  al,  2012)  •  “…medication  details  were  frequently  omitted  or  inaccurate  …lack  of  clarity  about  follow-­‐up  plans  regarding  further  investigations  and  visits  to  other  consultants  as  the  areas  requiring  the  most  improvement.”  (Legault  et  al,  2012)  

About Discharge Summary •  “…accurate  identification  of  clinical  abbreviations  is  a  challenging  task  and  advanced  abbreviation  recognition  modules  are  needed…”  (Wu  et  al,  2012)  •  “…audit  and  feedback  sessions  significantly  improved  the  completeness  of  discharge  summaries  dictated  by  geriatric  medicine  fellows  at  one  academic  medical  center.”  (Dinescu  et  al,  2011)  •  “An  Electronic  Discharge  Summary  program  can  be  used  by  housestaff  to  more  easily  create  hospital  discharge  summaries…”  (Maslove  et  al,  2009)  

Unreliable Discharge Summary, then? • Admission  form  •  Integrated  medical  record  •  Medical  •  Nursing  •  Other  health  profession  

•  Surgery  report  •  Supporting  results  •  Laboratory  •  Radiology  /  Imaging  •  Electromedics  

• Others  •  Transfusion  “flag”  

http://a57.foxnews.com/  

Koleksi  Pribadi  

Koleksi  Pribadi  

Koleksi  Pribadi  

Koleksi  Pribadi  

Koleksi  Pribadi  

LABORATORIUM RUMAH SAKIT PANTI RAPIH

NAMA :RUPER :

REGISTER :

ARIAN DATUSANANTYO ROBERTUS DR BPLUAR

RM : 014323

UMUR :31 TH 11 BL 8 HR JENIS KELAMIN LDOKTER : APS

TANGGAL :25/02/2014 10:37:01

PEMERIKSAAN HASIL RUJUKAN SATUAN KET

:

METODE

JL. TEUKU CIK DITIRO 30 YOGYAKARTATELP. 0274-563333, 562233, 514845

Penaggung Jawab Laboratoriumdr. Tri Djoko Endro Susilo, Sp PK

NO. LAB : 1402250237

HEMATOLOGI Hemoglobin 15.5 g%13.0 - 17.0 Hema-Automatic Lekosit 5.0 10^3/ul4.0 - 11.0 Hema-Automatic Eritrosit 5.28 10^6/ul4.50 - 6.50 Hema-Automatic Hematokrit 47.3 %40.0 - 54.0 Hema-Automatic Trombosit 202 10^3/uL150 - 450 Hema-Automatic HITUNG JENIS LEKOSIT Eosinofil 5.9 %1.0 - 6.0 Hema-Automatic Basofil 0.7 %1.0 - 2.0 LHema-Automatic Neutrofil 54.4 %40.0 - 80.0 Hema-Automatic Limfosit 26.5 %20.0 - 40.0 Hema-Automatic Monosit 12.6 %2.0 - 10.0 HHema-Automatic INDEKS ERITROSIT MCV 89.6 fl80.0 - 96.0 Hema-Automatic MCH 29.3 pg27.0 - 31.0 Hema-Automatic MCHC 32.8 g/dl32.0 - 36.0 Hema-Automatic RDW-CV 13.3 %11.6 - 14.8 Hema-Automatic

Kalau ada keraguan hasil,Harap segera menghubungi instalasi laboratorium

Catatan : Yogyakarta, 25 FEBRUARI 2014

Disetujui

WAWAN

11:46:27

Cetak : 05/03/2014 12:24:25

dicetak oleh 10035

hal 1 dari 1

Koleksi  Pribadi  

Koleksi  Pribadi  

Koleksi  Pribadi  

Koleksi  Pribadi  

Case Mrs  S.W.,  female,  53  y.o.  was  referred  by  a  medical  oncologist  to  our  internal  medicine  ward.  She  was  diagnosed  with  a  Non-­‐Hodgkin  Lymphoma  and  an  advanced  grade  of  Haemorrhoid.    She  had  a  surgery  during  her  13-­‐day  hospitalization  and  received  supportive  treatment  for  her  NHL,  tranfusion  of  packed  red  cells,  and  antibiotics  for  amebic  gastroenteritis.  Her  discharge  summary  was  completed  by  the  medical  oncologist  without  stating  anything  about  surgery  and  surgeon  consultation.    The  swap  between  primary  and  secondary  diagnoses  was  performed  by  the  coder  and  she  found  an  interesting  fact.  A  modification  of  DS  is  therefore  necessary.    

Common Problems • Unrecognizable  handwriting  • Different:  admision  and  discharge  diagnosis  •  Common  diagnosis  confusion:  •  Post  laparatomy  •  Post  partum  •  Abbreviation  

• Medical  procedure  confusion:  •  Incomplete  •  Abbreviation  

• Unrecorded  consultation  •  Primary  and  secondary  diagnoses  vs  attending  phycisians’  role  •  Tariff  consideration  (?)  

http

://www.pha

rmac

yerror

injurylawye

r.com

/  

Source:  Interview  with  Coders  

http://www.commonsenseevaluation.com/  

Fraud and Abuse. Corruption?

https://www.unodc.org  

•  Fraud:  Intentional  deception  or  misrepresentation  that  the  individual  or  entity  makes  knowing  that  the  misrepresentation  could  result  in  some  unauthorized  benefit  to  the  individual,  or  the  entity  or  to  some  other  party.  (NHCAA,  2012)  • Abuse:  Unintentional  practice  that  directly  or  indirectly  results  in  an  overpayment  to  the  healthcare  provider.  (Rudman  et  al,  2009)    •  Corruption  (Riyanto,  2009)  •  Desire  to  act,  •  Ability  to  act,  •  Opportunity  to  do  corruption,  •  Suitable  target.  

Intervention in Fraud •  “…a  lack  of  evidence  of  effect  of  the  interventions  to  combat  health  care  fraud.”  (Rashidian,  2012)  •  “Do  EHRs  and  other  healthcare  IT  lead  to  increased  fraud  compared  to  paper  medical  records?  Again,  we  do  not  know  the  answer  definitively.  It  has  not  been  properly  studied.  Such  studies  are  difficult  to  perform,  and  true  controlled  studies  are  impossible.”  (Simborg,  2011)  •  "Yang  kami  tangkap,  ada  lima  titik.  Investasi  dana  badan  itu,  investasi  dana  jaminan  sosial,  potensi  korupsi  saat  pengalihan  aset,  potensi  korupsi  penggunaan  dana  operasional,  potensi  korupsi  saat  pembayaran  di  fasilitas  kesehatan.  Kami  berterima  kasih  kepada  KPK  yang  mengingatkan  kami  karena  mencegah  itu  lebih  baik  daripada  mengobati,”  (Idris,  2014)  

Conclusion

http://networkingstar.com  

• Medical  records  are  the  only  source  of  information  available  for  DRG/CBG  coding  è  Quality  variation.  •  Indonesian  hospitals  are  interested  only  in  “reimbursement  factor”.  •  Completeness  checking  before  DS  goes  to  coder.  •  Internal  audit:  medical  record,  DS,  coding.  • DRG/CBGs  improves  coding  practice?  • Willingness  to  prevent  fraud  and  abuse:  upcoding,  unbundling.  

Thank You! The  content  of  this  presentation  is  author’s  responsibility  and  not  necessarily  reflects  organization’s  view  of  this  topic.  The  author  declares  no  competing  interest.  All  references  used  are  stated  below.  All  picture  sources  are  stated  below  each  picture.    

@robertus_arian  |  arian9677@gmail.com  

References (1) •  Pongpirul  K,  Walker  DG,  Rahman  H,  Robinson  C;  DRG  coding  practice:  a  nationwide  hospital  survey  in  Thailand;  BMC  Health  Services  Research  2011,  11:290    

•  Pongpirul  K,  Walker  DG,  Winch  PJ,  Robinson  C;  A  qualitative  study  of  DRG  coding  practice  in  hospitals  under  the  Thai  Universal  Coverage  Scheme  ;  BMC  Health  Services  Research  2011,  11:71    

•  Pourasghar  F,  Hossein  M,  Kazemi  A,  Ellenius  J,  Fors  U;  What  they  fill  in  today,  may  not  be  useful  tomorrow:  Lessons  learned  from  studying  Medical  Records  at  the  Women  hospital  in  Tabriz,  Iran;  BMC  Public  Health  2008,  8:139  

•  Adeleke  IT,  Adekanye  AO,  Onawola  KA,  Okuku  AD,  Adefemi  SA,  Erinle  SA,  Shehu  AA,  Yahaya  OE,  Aebisi  AA,  James  JA,  AbdulGhaney  OO,  Ogundiran  LM,  Jibril  AD,  Atakere  ME,  Achinbee  M,  Abodunrin  OA,  Hassan  MW;  Data  quality  assessment  in  healthcare:  a  365-­‐day  chart  review  of  inpatients’  health  records  at  a  Nigerian  tertiary  hospital;  J  Am  Med  Inform  Assoc  2012;19:1039–1042    

References (2) •  Legault  K,  Ostro  J,  Khalid  Z,  Wasi  P,  You  JJ;  Quality  of  discharge  summaries  prepared  by  first  year  internal  medicine  residents;  BMC  Medical  Education  2012,  12:77  

•  Wu  Y,  Denny  JC,  Rosenbloom  ST,  Miller  RA,  Giuse  DA,  Xu  H;  A  comparative  study  of  current  clinical  natural  language  processing  systems  on  handling  abbreviations  in  discharge  summaries;  AMIA  Annu  Symp  Proc.  2012:  997-­‐1003  

•  Dinescu  A,  Fernandez  H,  Ross  JS,  Karani  R;  Audit  and  feedback:  an  intervention  to  improve  discharge  summary  completion;  J  Hosp  Med.  2011  January  ;  6(1):  28–32  

•  Maslove  DM,  Leiter  RE,  Griesman  J,  Arnott  C,  Mourad  O,  Chow  C,  Bell  CM;  Electronic  Versus  Dictated  Hospital  Discharge  Summaries:  a  Randomized  Controlled  Trial;  J  Gen  Intern  Med  24(9):995–1001    

References (3) •  NHCAA  (US);  A  Private-­‐Public  Partnership  Against  Health  Care  Fraud  [Internet];  US:  National  Health  Cara  Anti-­‐Fraud  Association;  Consumer  Info  &  Action;  Available  at  http://www.nhcaa.org/resources/health-­‐care-­‐anti-­‐fraud-­‐resources/consumer-­‐info-­‐action.aspx;  Accessed  March  4th,  2013  

•  Rudman  WJ,  Eberhardt  III  JS,  Pierce  W,  Hart-­‐Hester  S;  Healthcare  Fraud  and  Abuse;  Perspectives  in  Health  Information  Management  6,  Fall  2009    

•  Pernyataan  Bibit  S.  Riyanto  (2009)  dikutip  oleh  Niken  Ariati  dalam  seminar  Strategi  untuk  mencegah  Fraud  dan  Korupsi  di  Jaminan  Kesehatan  Nasional;  Jakarta;  November  2013;  Available  at  http://kebijakankesehatanindonesia.net/component/content/article/2232.html  

•  Rashidian  A,  Joudaki  H,  Vian  T;  Health  Care  Fraud  and  Abuse:  A  Systematic  Review  of  Literature;  PLoS  ONE  7(8):  e41988.    

References (4) •  Simborg  DW;  There  is  no  neutral  position  on  fraud!;  J  Am  Med  Inform  Assoc  2011;18:675e677.    

•  Pernyataan  Fahmi  Idris  (2014)  dikutip  oleh  Kompas  Online;  Available  at  http://nasional.kompas.com/read/2014/02/11/1501433/KPK.Temukan.Lima.Titik.Rawan.Korupsi.Pengelolaan.JKN.oleh.BPJS