The AHIMA World Congress (AWC) team used gap analysis to report new opportunities for Al Ain Hospital in the UAE.
EDITOR’S NOTE: Dr. Lo will be a guest speaker during today’s edition of Talk Ten Tuesdays, and he offered the following thoughts with ICD10monitor ahead of the appearance.
I am delighted to share with you a word of exciting opportunities for clinical documentation improvement (CDI) in the United Arab Emirates (UAE).
In order to appreciate CDI in the UAE, I would like to frame this discussion by providing a general overview of the methodology of International Refined Diagnosis Related Groups (IR-DRGs), which are utilized by many countries, including the UAE.
IR-DRGs, designed by 3M for international healthcare, are versatile and code-independent. This means that IR-DRGs provide results in classifying patients, regardless of the type of coding systems used, and allows for uniform comparisons across countries. In the UAE, IR-DRGs are used for ambulatory and inpatient facility reimbursement and are generated from ICD-10-CM diagnosis codes and CPT-4 procedure codes. ICD-10-PCS codes are not utilized to generate IR-DRGs in the UAE.
In Medicare Severity Diagnosis-Related Groups (MS-DRGs) and All Patient Refined Diagnosis Related Groups (APR-DRGs), diagnoses form the primary axis of classification. With IR-DRGs, however, procedures form the primary axis of classification.
IR-DRGs contain seven digits: the first and second digits correspond to the Major Diagnostic Category (MDC); the third digit corresponds to the DRG type (e.g., inpatient procedure, ambulatory significant procedure, inpatient medical); the fourth and fifth digits correspond to the DRG; the sixth digit corresponds to the severity of illness (SOI) subclass; and the seventh digit (optional) corresponds to the risk of mortality (ROM) subclass. For instance, IR-DRG 014142 corresponds to MDC 01, “Diseases & Disorders of the Nervous System” (first and second digits “01”), Inpatient Medical DRG (third digit “4”), DRG 14 “Cerebrovascular Accident with Infarct” (fourth and fifth digits “14”), and SOI subclass 2 (sixth digit “2”).
IR-DRGs have similar grouper logic and algorithm as APR-DRGs, which are utilized in the United States. APR-DRGs have four subclasses (1 = “Minor,” 2 = “Moderate,” 3 = “Major,” and 4 = “Extreme”) for severity of illness (SOI) and risk of mortality (ROM). In contrast, IR-DRGs have three subclasses (1 = “Minor,” 2 = “Moderate,” 3 = “Major”) for SOI and ROM. IR-DRG SOI subclasses “1,” “2,” and “3” correspond to “without CC,” “with CC,” and “with MCC,” respectively, in which “CC” stands for “complications and comorbidities” and “MCC” stands for “major complications and comorbidities.”
The APR-DRG grouper logic is complex. In general, two secondary diagnoses with SOI 4 or a combination of secondary diagnoses with SOI 3 and SOI 4 are required to generate composite APR-DRG SOI 4 (“Extreme”). There are multiple steps and caveats in determining the composite APR-DRG SOI, such as eliminating any secondary diagnoses associated with the principal diagnosis and redundant with other secondary diagnoses.
In the grouper logic of IR-DRGs, the determination of the composite IR-DRG SOI hinges solely on the secondary diagnosis with the highest SOI score. This precludes the need to capture multiple, secondary diagnoses with SOI 3, in order to arrive at composite IR-DRG SOI 3. This creates an exciting opportunity for CDI.
Assume that an inpatient discharge has composite IR-DRG SOI 1. If a query is generated to clarify documentation for a secondary diagnosis with SOI 3 (e.g., acute respiratory failure) and the physician agrees with the query, the composite IR-DRG SOI will shift from 1 to 3, with a marked increase in IR-DRG relative weight and length of stay (LOS). In this case, only one secondary diagnosis – acute respiratory failure with SOI 3 – is required to arrive at composite IR-DRG SOI 3.
The American Health Information Management Association (AHIMA) World Congress (AWC) team generated a comprehensive gap analysis report for its newest organizational member, Al Ain Hospital (AAH), a state-of-the-art, 402-bed acute care and emergency hospital in the UAE. The gap analysis was based on thorough review and assessment of AAH sample records, as well as analysis of case mix index (CMI), SOI/ROM, IR-DRG and LOS metrics, survey responses, and on-site meetings and interviews.
Opportunities were identified to increase the quality of clinical documentation, optimize patient care and safety, and streamline services. In a significant percentage of AAH sample records, there were opportunities for CDI query generation with a positive impact on revenue and public reporting via increasing IR-DRG relative weights, increasing composite IR-DRG SOI/ROM scores, and/or decreasing LOS. Here are some examples of query opportunities:
- For MDC 05 (“Diseases & Disorders of the Circulatory System”), change working IR-DRG 051201 (inpatient procedure IR-DRG) with relative weight 1.9627 and SOI 1 to target IR-DRG 051202 (inpatient procedure IR-DRG) with relative weight 2.7972 and SOI 2. The relative weight of the target IR-DRG is almost 1.5 times the relative weight of the working IR-DRG.
- For MDC 01 (“Diseases & Disorders of the Nervous System”), change working IR-DRG 014141 (inpatient medical IR-DRG) with relative weight 0.7984 and SOI 1 to target IR-DRG 014143 (inpatient medical IR-DRG) with relative weight 3.565 and SOI 3. The relative weight of the target IR-DRG is almost 4.5 times the relative weight of the working IR-DRG.
- For MDC 04 (“Diseases & Disorders of the Respiratory System”), change working IR-DRG 044181 (inpatient medical IR-DRG; DRG “18”) with relative weight 0.3366 and SOI 1 to target IR-DRG 044112 (inpatient medical IR-DRG; DRG “11”) with relative weight 2.0041 and SOI 2. The relative weight of the target IR-DRG is almost six times the relative weight of the working IR-DRG.
- Also, opportunities were found to decrease the number of denials and appeals denied after submission, based on clinical validation and query generation to clarify diagnoses and procedures.
Based on comparing UAE hospitals with hospitals in the United States, AWC estimates that UAE hospitals can possibly generate between $4 million USD and $7.5 million USD in additional revenue each year, once a CDI program is implemented, streamlined, and optimized.