How Can a Profee Coder Learn DRG

Q: “How can a profee coder learn DRG?”

Coach Alicia: I think they see DRG and they get scared.

Coach Schuyler: It’s not scary.

A: We are going to be talking about a little bit of the differences of coding. We always hear about profee so most people don’t understand or know what profee means so that just means the professional fee coders and those really look at the professional fees of physicians, so this is more in the outpatient side or even you can work for a hospital system that have medical groups attached to it. This is what you’ll be doing as well.

So, I wanted to talk a little bit about the differences between these. There’s more than just these three types, like the general. The Hospital Outpatient Coders really look at all the conditions and procedures that the provider documents and also in the emergency settings that support the facility billing only. Obviously, some outpatients, you can be looking at some of these profee areas as well, so it depends on your role, knowing previous roles of mine that I was working on their profee side. But we had some members on my team, the compliance team, that worked more on their facility side working with them on their facility-based coding.
Facility Inpatient Coders - This is where we’re going to be digging into the DRG. DRGs which is the diagnosis related groups. This is more with inpatient and how much resource did those services for that patient during their hospital stay.

How much resources did they absorb? That’s really what you look at. Diagnosis sequence is important in any coding that you do, knowing your coding guidelines. That there are specific guidelines regarding sequencing, especially sepsis that’s one of things that you really want to understand, as well as HIV-related coding guidelines.
Not only what does DRG look at, diagnoses, procedures, but also any comorbidities or complications, which is also known as CC. You’ll see a lot of abbreviations used in inpatient settings. You have the DRG, there are actually different varieties of DRG, but you also have the CC which is the comorbidities and complications, and then MCC, so major complications and comorbidities. Those things you see a lot, and actually if you have AAPC’s ICD-10-CM manual, there actually are symbols to the right of each code if they’re applicable to the symbol, that will indicate if it’s a CC, MCC, HCC, or RxHCC for those that are risk adjusted coders. So, that’s a wonderful tool to have. I know I have mine regarding this because of my role as a fraud investigator for a health plan in the risk adjustment side.

When the facility looks at or reviews documentations for this, they look for any supplies or any other services that are used and that’s provided by that facility; any of the bedrooms that’s used where the patient stays during their visit and any procedures or anything that happens or develops during their hospitalization stay. This is where we we really want to focus on. This is why whenever a patient is admitted, this is what they call a working DRG, so it’s not a final one, but it’s one of those that are developed. Obviously, there are some instances and conditions that are hospital acquired so that obviously plays an effect in your DRG assignment and can impact the financial side of how much that facility will be reimbursed because you are dinged for a specific HAC or hospital-acquired conditions.

What is a DRG? As we said before, DRG is a Diagnosis Related Group. This classifies different hospital cases regarding diagnoses, procedures, age, sex, discharge status. Discharge status is an important factor of DRGs, as well as POAs or present on admission, and we’ll be talking about that in a little bit.
DRGS are for reimbursement and that replaces that “cost based” reimbursement or payment methodology that was onced used by Medicare and other payers. Now, we always hear about this performance-based reimbursement or payment methodology, so this is where we’re coming from.

What is Case Mix Index? What you hear a lot about in DRG is the CMI or case mix Index. This is an important part on how it impact your overall scores, how you are assigning your DRGs. This determines the allocation of resources that are being used for the patient. Obviously, the higher CMI that you have for that patient, obviously to a payer or somebody that does the reimbursement, it means that the patient has had more complications or more resources were allocated to that patient for the services and that’s an important thing to understand and for the providers to document.

If any those who have taken the CCS, certified coding specialist from AHIMA, DRGs are actually an important part of that exam. Obviously, the CCS exam has all varieties of information that they’ll be testing you on, but AHIMA is really focused on IT, but inpatient information. So, you’ll get hit heavily with the DRGs and inpatient-related information.