As a Physician Advisor, I’ve seen firsthand how critical a robust Diagnosis-Related Group (DRG) validation process is to hospitals’ financial and operational health. In an environment where accurate documentation and coding directly impacts revenue, compliance, and the quality of patient care, establishing a well-defined process for DRG validation is not just an option—it’s essential.
Why DRG Validation Matters to Physicians
From my experience, DRG validation is about more than just billing. Ultimately, it’s about ensuring the patient’s clinical story is adequately reflected in the documentation and codes. This alignment is critical for several reasons:
- Accurate Reimbursement: As physicians, we know that the complexity of our patient’s conditions is only sometimes fully captured in the initial coding. Additionally, hospitals can lose substantial revenue when documentation doesn’t reflect the actual severity of illness.
- Reducing Denials: Denied claims place a significant administrative burden on hospitals and clinicians. Validating DRGs ensures that the documented and coded are clinically valid and aligned with coding guidelines, reducing the risk of costly denials.
- Compliance and Audit Readiness: Physicians are held to high standards of care and documentation. A robust DRG validation process helps ensure compliance with coding guidelines, reducing the likelihood of audits and penalties related to high-risk DRGs.
- Quality Measure Performance: Many hospital quality measures such as those within the Center for Medicare and Medicaid Services (CMS) value-based purchasing measures are based entirely on the coded record rather than clinical outcomes. However, this discordance can result in low quality measure performance if the coded record is not an accurate and complete picture of the patient’s conditions and course.
The Power of Collaboration
The most successful DRG validation efforts involve collaboration between multiple teams. CDI specialists, coding professionals, and Physician Advisors each play a vital role:
- CDI Specialists: With their clinical expertise, CDI teams help ensure documentation accuracy and clinical validity. They often identify documentation gaps that can be corrected before coding occurs.
- Coding Experts: Coding professionals ensure the codes applied are accurate and in line with current regulations. They bridge the gap between clinical documentation and the billing process, ensuring that the hospital is reimbursed appropriately.
- Physician Advisors: Provide additional clinical insight, and a unique perspective needed to ensure that the DRGs accurately reflect the patient’s clinical condition. Our involvement often helps resolve clinical documentation discrepancies, improve queries, and provide necessary education to achieve more accurate coding and improved compliance.
CDIs and coders review cases concurrently, but an additional second-level review may be valuable for certain DRGs. Analogous to clinical workflows, redundancy through collaborative efforts—such as two nurses verifying a high-risk medication dose—helps reduce clinical errors. Although multiple checks within CDI and coding are not always feasible, applying this concept can reduce revenue leakage and improve compliance by ensuring that the coding and documentation in certain cases are accurately reflected in the claim codes
Our Results at Brundage Group
At Brundage Group, I’ve been proud to be a part of a team of CDI, coding professionals and Physician Advisors that have delivered exceptional results through our DRG Validation Reviews:
Taking Action as a Physician Advisor
For Physician Advisors like me, being actively involved in DRG validation has allowed me to bridge the gap between clinical care and the administrative side of healthcare. Moreover, it’s not just about ensuring the hospital gets paid; it’s about ensuring that the patient’s story is accurately documented and that we, as clinicians, are correctly credited for the complexity of the care we deliver.
If you’re a Physician Advisor or hospital leader, I strongly urge you to participate actively in DRG validation. The impact goes beyond finances—it ensures compliance, reduces denials, and improves the overall quality of care.
By Michael Trelow, CSTR, CAISS
What is Critical Thinking?
Critical thinking is defined as the “objective analysis and evaluation of an issue to form a judgment.” Key terms in this definition include objective analysis, evaluation, and judgment, which are essential components of the process. Critical thinking fosters effective problem-solving and creativity, and it underpins rational decision-making.
Below are realistic examples of how critical thinking resolved an issue for trauma registry professionals. The process of critical thinking involves five distinct phases.
Phases of Critical Thinking
Results and Impact of Critical Thinking
By employing critical thinking techniques, the trauma service was able to quickly obtain EMS trip sheets. Initially, when the trauma service began distributing custom reports, it took some time for EMS agencies to recognize their value. However, once they did, they eagerly incorporated the reports into their performance improvement processes.
Over time, EMS agencies began contacting the Trauma Registry Professionals within 24 hours of patient drop-off to inquire about their reports. If they hadn’t left a trip sheet, the registrar would inform them, and the EMS agency would promptly send it over within five minutes. This change significantly reduced the time the Trauma Registry Professional spent on Mondays calling for trip sheets, from up to four hours to just 30 minutes. As a result, the trauma service received the trip sheets immediately and could promptly deliver reports back to the EMS agencies, enhancing communication between the two parties.
While no one is perfect at critical thinking, consistent practice offers a significant advantage. Strong critical thinking skills enable us to understand ourselves and our opinions better, and to examine diverse perspectives without fear or bias. These skills are invaluable tools for proactively addressing problems in both personal and professional contexts.
By Michael Trelow, CSTR, CAISS
Data validation serves as a critical educational tool for Trauma Registry Professionals, enhancing their skills, improving data quality for trauma centers, and ultimately contributing to better patient care. The process of validation highlights areas of weakness and encourages registrars to seek further training, ensuring that data entry remains accurate.
Various methods of data validation exist for the trauma registry, allowing trauma centers to select tools that best fit their needs. The primary goal is to ensure Trauma Registry Professionals extract the most accurate data from the electronic health record (EHR) and transfer it to the registry.
The Guidelines
The National Trauma Data Standard (NTDS) serves as the essential data dictionary for all trauma registrars. It details all required data fields, providing definitions, element values, and additional information to ensure correct data entry. The NTDS includes a data source hierarchy guide, directing registrars to the appropriate documents for data retrieval. It also outlines associated edit checks, specifying that Level 1 and 2 edit checks must be corrected before data can be uploaded to the National Trauma Data Bank (NTDB).
Some states use statewide trauma data dictionaries that adhere to the NTDS format while tracking additional data fields. Hospital-based data dictionaries are designed to indicate where to obtain data from the electronic health record (HER). They should include an additional column specifying the exact location in the EHR to pull the data. This will assist new registrars in accurately entering data into the trauma registry.
According to the American College of Surgeons (ACS), up to 10% of the total charts per month must be validated. There are two schools in data validation of the trauma registry:
Continues Improvement through Validation
In data validation, you aim to identify patterns of missed or incorrect data. If a pattern is detected, you can guide the registrar to relevant courses to improve their understanding. Options include trauma registrar courses, International Classification of Diseases Courses (ICD-10), and Abbreviated Injury Scale Courses (AIS). Sharing validation scores on a shared drive allows the Trauma Program Manager and Trauma Medical Director to quickly review the inter-rater reliability (IRR) of the trauma registrars, ensuring high-quality reports from the registry.
In conclusion, there are many ways to validate a record for the Trauma Registry Professional. The main point is to be educational because no one is perfect. It should be a two-way street where the reviewer identifies the missing/incorrect data, presents it to the registrar and the registrar can show the reviewer where they got the data. All of this is done to help the registrar abstract and enter high-quality data to help the hospitals improve the treatment of the injured patient.
Ready to Strengthen Your DRG Validation Process?
Don’t wait for audits or denials to highlight the gaps in your documentation and coding. Take proactive steps to ensure compliance and maximize your revenue. Connect with Brundage Group today and let our Physician Advisors and experts help your hospital build a more substantial, more efficient DRG validation process.
