optimal drg assignment is based on

Mastering MS-DRG Assignments to Enhance Reimbursements

Executives of hospital management often overlook medical coding as a contributing factor to the revenue cycle – but it’s a crucial link between earning well-deserved reimbursements from the services performed. One such revenue-defining coding system is the Medicare Severity Diagnosis Related Group (MS-DRG), which utilizes ICD-10 diagnosis and procedure codes , and other factors, such as age, sex, and discharge disposition, to facilitate payment for Inpatient services. In this introduction to MS-DRG assignments, we’ll explore examples of DRGs and introduce invaluable resources for selecting the correct DRG, including a DRG list and DRG assignment software.

What is Medicare Severity Diagnosis Related Group (MS-DRG) Coding?

MS-DRG is a sophisticated classification system that holds the power to categorize patients and their medical cases based on clinical characteristics and the resources required for their care (CMS, 2023). Each patient’s case is assigned a specific DRG, encapsulating diagnoses, procedures, age, sex, MCCs, CCs, and other relevant factors. These codes effectively communicate the complexity and intensity of services provided, determining reimbursement levels for hospital stays. Introduced by the Centers for Medicare and Medicaid Services (CMS), this system streamlines the payment process for Inpatient services.

It serves as a universal language, allowing healthcare providers to effectively communicate the complexity and intensity of services rendered. By assigning specific DRGs to patient cases, hospitals can accurately capture the intricacies of each scenario, leading to fair reimbursement and improved financial outcomes.

Accurate DRG assignment plays a pivotal role in directly impacting a hospital’s or facility’s reimbursements and revenue cycle. Accurate and appropriate DRG assignment ensures that the severity and complexity of each patient case are effectively communicated, leading to proper reimbursement for the resources invested in their care. By assigning the correct DRG, hospitals can optimize their revenue potential by capturing the true value of the services provided.

Additionally, accurate DRG assignment helps healthcare organizations navigate complex payment structures and regulatory guidelines, reducing the risk of undercoding or overcoding, which can result in financial penalties or revenue loss. A streamlined and efficient revenue cycle relies heavily on accurate DRG assignment, ensuring that hospitals receive fair and adequate reimbursements for the care they deliver while maintaining financial stability and sustainability.

DRG Examples

To grasp the practical application of DRG assignments, let’s explore some examples.

Patient admitted with the principal diagnosis of acute myocardial infarction is impacted when a percutaneous cardiovascular procedure is performed with drug-eluting or non-drug eluting stents or arteries.

DRG 246 PERCUTANEOUS CARDIOVASCULAR PROCEDURE WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS DRG 247 PERCUTANEOUS CARDIOVASCULAR PROCEDURE WITH DRUG-ELUTING STENT WITHOUT MCC DRG 248 PERCUTANEOUS CARDIOVASCULAR PROCEDURE WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS DRG 249 PERCUTANEOUS CARDIOVASCULAR PROCEDURE WITH NON-DRUG-ELUTING STENT WITHOUT MCC

MDC 05 Disease and Disorders of the Circulatory System

Percutaneous Cardiovascular Procedures with Coronary Artery/Stent Decision Tree

Patient admitted with the principal diagnosis of acute myocardial infarction is impacted when the patient has a major complication or comorbidity (MCC) or complication and comorbidity (CC) or not and whether the patient was discharged alive or expired.

DRG 280 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC DRG 281 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC DRG 282 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC DRG 283 ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC DRG 284 ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC DRG 285 ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC

Acute Myocardial Infarction and Principal Diagnosis Decision Tree

Patient admitted with the principal diagnosis of pneumonia is impacted when the patient has a major complication or comorbidity (MCC) or complication and comorbidity.

DRG 193 SIMPLE PNEUMONIA AND PLEURISY WITH MCC DRG 194 SIMPLE PNEUMONIA AND PLEURISY WITH CC DRG 195 SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

MDC 04 Diseases and Disorder of the Respiratory System

Simple Pneumonia as the Principal Diagnosis Decision Tree

DRG Resources

Here are several DRG resources to assist with appropriate assignment:

MS-DRG List:  This comprehensive DRG list from CMS includes  a vast range of codes  representing various medical cases, diagnoses, procedures, and patient profiles. This list enables healthcare providers to accurately assign the most suitable DRG, streamlining the reimbursement process and optimizing financial outcomes.

MS-DRG Grouper Software : An invaluable tool in correctly assigning DRGs is the MS-DRG Grouper software. The software calculates payments to cover the costs of an Inpatient encounter. The coder enters the ICD-10-CM/PCS codes into the software, and it calculates the MS-DRG based on those codes the user has selected. The MS-DRG payment equals the MS-DRG relative weight multiplied by the hospital blended rate.

Utilize Our Coding Support Services to Assign DRGs & Optimize Revenue

YES offers expert coding support services for DRG assignment, designed to streamline providers’ processes, ensure compliance, and maximize revenue potential. Here’s why you should choose our services:

• Expertise and Experience : Our highly skilled team of certified coding professionals possesses extensive knowledge and experience in coding and assigning DRGs. We remain current with the latest industry regulations and guidelines, guaranteeing accurate and comprehensive coding to maximize reimbursements.
• Compliance and Audit Readiness : We recognize the importance of compliance in healthcare. Our services ensure that your coding practices align with regulatory guidelines, safeguarding your organization from penalties and preparing you for any compliance audits.
• Revenue Optimization : By leveraging our DRG assignment and coding support services, you unlock the full revenue potential of your organization. Utilizing our customized trending reports, we identify areas for improvement, minimize coding errors, and provide actionable insights to enhance financial performance.

Mastering DRG assignment is essential for hospitals and healthcare organizations to achieve optimal reimbursements and operational efficiency.  Contact us today  to discuss how our  coding support services  can elevate your coding practices and drive superior outcomes.

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DRG Coding in Medical Billing:

by lishi | Feb 16, 2024 | Uncategorized | 0 comments

Medical billing and coding, particularly Diagnosis Related Group (DRG) coding, is vital in healthcare for accurate reimbursement. Explores DRG coding, emphasizing its significance and essential elements for healthcare professionals. Precision in coding is crucial for reimbursement and data analysis, making DRG coding a cornerstone in categorizing and reimbursing patients accurately.

Constituent parts:

• Principal Diagnosis: The main reason for a patient’s hospitalization.
• Secondary Diagnoses: Additional conditions that affect patient care and resource utilization.
• Procedures: Medical interventions and surgeries performed during hospitalization.
• Patient Demographics: Age, sex, and other demographic factors that influence resource needs.

Functioning:

Step 1. Data Collection: Thorough patient information, encompassing medical history, test results, and treatment details, is comprehensively gathered to lay the foundation for accurate coding.

Step 2. Code Assignment: Adept coders utilize established coding systems like ICD-10-CM/PCS to assign specific codes. These codes intricately capture every facet of the patient’s condition and treatment.

Step 3. DRG Assignment: The meticulously coded information serves as the key to DRG assignment, ensuring the precise alignment of the patient’s clinical profile with the appropriate reimbursement group. This precision is vital for accurate and fair reimbursement outcomes.

Step 4. Quality Assurance and Review: Rigorous quality assurance and review processes constitute the final layer, verifying the accuracy and completeness of assigned codes. These measures ensure compliance and contribute to optimal reimbursement outcomes.

Significance of Accurate DRG Coding:

Reimbursement Precision:   Ensuring equitable and accurate reimbursement for medical billing, proper DRG coding meticulously aligns financial compensation with the intricacies of the services rendered. By precisely categorizing the patient’s clinical profile. This ensures transparency, empowering medical billing facilities to deliver high-quality care without apprehensions about inadequate compensation.

Enhancing Care Quality: Integral to promoting healthcare quality, the DRG coding system serves as a catalyst for efficiency and judicious resource utilization. The direct correlation between coding accuracy and financial reimbursement motivates healthcare providers to streamline processes, minimize unnecessary interventions, and optimize resource allocation. This dual focus not only elevates overall care quality but also instills a culture of cost-effectiveness, balancing patient well-being and responsible resource management.

Statistical Insights: In addition to financial implications, DRG coding emerges as a valuable tool for statistical analysis in healthcare research. Through a standardized coding framework, researchers can systematically track disease trends, treatment outcomes, and resource allocation. This analytical approach yields valuable insights into treatment effectiveness, identifies evolving health patterns, and informs evidence-based policies for improved patient outcomes.

Optimal DRG Coding Practices:

• Continuous Education: Coders should engage in regular training programs to stay abreast of coding system updates and industry changes.
• Collaboration: Effective communication between coding professionals, clinicians, and administrators is crucial for accurate code assignment.
• Documentation Improvement: Encouraging detailed and specific documentation by healthcare providers improves coding accuracy.

In conclusion, DRG coding stands as a cornerstone for financial sustainability and quality patient care in medical billing. Understanding the intricacies of this coding system, addressing challenges, and implementing best practices are essential steps toward ensuring accurate reimbursement and contributing to the overall effectiveness of the healthcare industry. As we navigate the complexities of DRG coding, the commitment to precision and continuous improvement remains paramount for healthcare professionals.

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DRG – Tips to Optimize Reimbursement

December 7, 2021

Review & Validation of Diagnosis Related Groups (DRGs) To Optimize Reimbursement and Avoid Burnout

Written by: Makema Massey, BSHIM, RHIT, CCS, COCAS, CPC, CPC-I, CPMA

This article is for inpatient coder NERDS and provides a practical approach from one of our AIHC inpatient coding nerds (rather experts) addressing inpatient diagnosis related groups, or DRGs, reimbursement related to hospital Medicare billing. 

Feeling bored with payment classification, continuing education webinars, and submitting claims with coding and billing errors?

Working in health care reimbursement is challenging. Repetition can lead to rote behavior which, in turn, can lead to mistakes. Your employer is counting on your highest level of performance, so it is important to learn how to deal with this issue effectively. I’d like to share what works for me in hope that it may help with your path to improved performance.

I had dealt with this feeling of boredom for a while, it seemed useless, and I found myself wondering if there was ever an actual algorithm to making sure that claims were submitted “correctly.” I found myself constantly searching for ways to become fired up again about correct reimbursement to ultimately receive the current and most optimal reimbursement available.

1. Get out of the “rut” - do something different

Initially, coding, billing, submitting claims, and auditing is satisfying and fun! But doing the same thing over and over will eventually lead to burn out. Sometimes you can get in a rut in the processes of coding and billing and become “computerized” or “mechanical” in your approach. It just seems to have been a purpose that got lost somewhere along with Father Time. Rather than giving up or looking for a new career, find ways to spice it up! Take a deeper dive into what you are doing – such as:

• Reading the Centers for Medicare and Medicaid Services’ (CMS) Quality Improvement Organization Manual, Chapter 4 - Case Review document on DRG Validation Review. Here you will find effective and implementation dates, the purpose behind review, responsibilities, and rules to guide you.

The objective of DRG validation is to ensure that diagnostic and procedural information as well as the discharge status of the patient, as coded and described by the hospital on its claim, matches both the attending physician’s description and the information clearly documented in the patient’s medical record. You don’t say? Of course, we knew that. But wait, there is more.

2. Remind yourself of your objectives

How many times have you “zoned out” into space out of sheer boredom? I sure know that I have done this plenty of times. Rather than quit, always remember why you are doing this.

Improve how you query providers. Examine your approach, professional judgement and discretion related to information contained on the physician’s query form along with the rest of the patient’s medical record.

• If it is leading in nature or if it introduces new information, it is up to you to identify this and either follow your processes to fix the issue internally or report the issue otherwise.
• You are trained and experienced in coding to perform DRG validation functions in order to verify the accuracy of the facility’s coding of diagnoses and procedures that affect the DRG. Verify the hospital’s coding in comparison to the coding principles that you have the ability to find in the current ICD Coding Guidelines.

3. Be sure you have on the correct uniform – and I’m not talking about your jeans

Sometimes, the right outfit makes you feel great. With that in mind, be sure to be equipped with the Uniform Hospital Discharge Data Set (UHDDS) to perform great! Having the right tools makes a world of difference in validating diagnoses and, moreover, procedures.

The UHDDS guidelines are used by facilities to ensure that reporting of inpatient data elements is standardized. The Uniform Hospital Discharge Data Set specifies that all significant procedures are to be properly reported. These are procedures that are surgical in nature, have a procedural risk, anesthetic risk, and/or require specialized training.

Remember, you only have the minimum core requirements of data with the UHDDS on hospital discharges and ICD-10-PCS procedural coding guidelines that go beyond the scope of the UHDDS are still required. You should also review HACS (Hospital Acquired Conditions). Visit the CMS ICD-10 HAC List webpage.

4. Take short, frequent breaks

Sometimes, burnout happens because our brains are telling us to take a natural break. It may be time to do nothing and relax….which means time away from screens (including your phone). 

Spending long hours staring at a screen definitely takes a toll on your body, especially your eyes. Excessive screen time not only strains your eyes and leaves them feeling dry, but can also lead to retina damage and blurred vision. The amount of screen time you clock has a direct impact on how much sleep you are getting, given that the blue light emitted from digital screens interferes with the production of the sleep hormone melatonin in your body. I suggest reading more on this topic from Scripps and remember these tips:

• While working on a computer, look away and at a distant object for about 20 seconds every 20 minutes — set a reminder if necessary
• Take a quick standing stretch break every hour
• Learn a few “chair yoga” stretches to keep muscles loose
• Pay attention to your posture
• Don’t eat in front of a screen
• Avoid backlit screens for an hour before bed
• Note how long you spend on electronic devices and replace some of that with physical activity and social interaction

After a break you can now come back and take a fresh look at your coding, procedural facility specific, UHDDS, CMS, and other helpful guidances to ensure accuracy.

5. Focus! Accuracy is key and hyper-focus is required for your job!

Reduce wasted time by focusing on the principal diagnosis, any major comorbid conditions and complications, and surgical procedures. The coder is not required to add additional diagnoses or procedures on a claim, unless of course they affect the DRG.

Focus: Is the principal diagnosis the one in the medical record that, after study, is determined to have occasioned the patient’s admission to the hospital?

Focus: Are there other diagnoses that have no bearing on the current hospital stay? Delete them!

Focus: Are all reported procedures that affect the DRG on the claim? If additional procedures can be reported, first make sure that they affect the DRG.

Great you are focused! Now finish strong!

Follow through with making sure you verify the patients discharge status, age, as well as their sex as these factors are verified by the MAC prior to your validation and most importantly, no effect on the DRG, no matter!

Are you charged with producing information for your CFO related to Medicare Cost Reports? Another way to learn more about the financial aspects of institutional finances is to attend the next Medicare Cost Report training camp! Locate the next camp date and location . If cost reporting is not part of your job, consider learning more about becoming a Certified Healthcare Auditor .

References:

• “The Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements.” Federal Register 50, no. 147. July 1985.
• Centers for Medicare and Medicaid Services. (2014, October 10). CMS Manual System. Centers for Medicare and Medicaid Services. Retrieved November 29, 2021, from https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R18QIO.pdf
• https://www.scripps.org/news_items/6626-how-much-screen-time-is-too-much

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Knowledge Base Article

FY 2020 IPPS Final Rule: Part 2 MS-DRGs

NOTE: All in-article links open in a new tab.

Tuesday, August 27, 2019

At least annually, DRG classifications and relative weights are adjusted to reflect changes in treatment patterns, technology, and other factors that may change the relative use of hospital resources. This week is the second article in our series about the 2020 IPPS Final Rule. This week highlights finalized changes to specific MS-DRG Classifications.

Extracorporeal Membrane Oxygenation (ECMO)

In FY 2019, three new procedure codes were finalized describing different types of ECMO treatments being used (central and peripheral). However, the codes were not finalized prior to the release of the FY 2019 IPPS Proposed Rule meaning there was no proposed Major Diagnostic Category (MDC), MS-DRG or O.R. vs. Non-O.R. designation made for the new codes.  

Given this unique situation, CMS Clinical Advisors reviewed the predecessor central ECMO code (5A15223) and determined the new peripheral codes should not sequence to Pre-MDC MS-DRG 3 where the central ECMO code is assigned.

Instead the new Peripheral ECMO codes were designated as Non-O.R. Procedures impacting MS-DRG assignment for specific medical MS-DRGs. The following table reflects the differences in ECMO Procedures DRG assignment:

In the FY 2020 IPPS Proposed Rule, stakeholders expressed the following concerns:

• MS-DRG assignment for ECMO should not be based on how the patient is cannulated as most of the cost can be attributed to a patient’s severity of illness,
• There was a lack of opportunity for public comment on the final MS-DRG assignments,
• Patient access to ECMO treatment and programs is now at risk because of inadequate payment, and
• CMS did not appear to have access to enough patient data to evaluate for appropriate MS-DRG assignment.

In the Final Rule CMS finalized the following proposals:

• Reassign the procedure codes describing peripheral ECMO procedures from their current MS-DRG assignments to Pre-MDC MS-DRG 003,
• Maintain the designation of the peripheral ECMO procedures as non-O.R., and
• Make changes to the titles for MS-DRGs 207, 291, 296, and 870 to no longer reflect the ECMO terminology in the title.

Allogenic Bone Marrow Transplant

A request was made to create new MS-DRGs for cases that would identify patients undergoing an allogeneic hematopoietic cell transplant (HCT) procedure according to the donor source (related or unrelated donor source). The requester indicated this would more appropriately recognize the clinical characteristics and cost differences in allogeneic HCT cases.

CMS data analysis of MS-DRG 014 cases reporting HCT related donor source, HCT unrelated donor source and unspecified donor source had comparable average length of stay and average costs. Thus, no proposal was made to create new MS-DRGs.

However, as a result of CMS’ review of procedure codes they proposed and finalized:

• The reassignment of 4 ICD-10-PCS codes for HCT procedures specifying autologous cord blood stem cell as the donor source from MS-DRG 014 to MS-DRGs 016 and 017, and
• Delete 128 clinically invalid codes from the transfusion table describing arterial access as transfusion procedures always use venous access rather than arterial access.

Chimeric Antigen Receptor (CAR) T-Cell Therapy

“Chimeric Antigen Receptor (CAR) T-cell therapy is a cell-based gene therapy in which a patient’s own T-cells are genetically engineered in a laboratory and used to assist in the patient’s treatment to attack certain cancerous cells. Blood is drawn from the patient and the T-cells are separated. The laboratory then utilizes the CAR process to genetically engineer the T-cells, resulting in the addition of a chimeric antigen receptor that will bind to a certain protein on the patient’s cancerous cells. The CAR T-cells are then administered to the patient by infusion.”

Two CAR T-cell therapy drugs received FDA approval in 2017 (KYMRIAH™ manufactured by Novartis Pharmaceuticals Corporation and YESCARTA™ manufactured by Kite Pharma, Inc.). Current ICD-10-PCS procedures codes involving the CAR T-cell therapy drugs includes:

• XW033C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into peripheral vein, percutaneous approach, new technology group 3), and
• XW043C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into central vein, percutaneous approach, new technology group 3).

Both ICD-10-PCS procedure codes became effective October 1, 2017 and are designated as non-O.R. procedures impacting MS–DRG assignment.

In FY 2019 CMS finalized the assignment of these procedure codes to Pre-MDC MS-DRG 016, revise the title of MS-DRG 016 to include “or T-cell immunotherapy,” and Car T-cell therapy was approved for a new technology add-on payment.

In the FY 2020 IPPS Proposed Rule, a request was made to create new MS-DRGs for CAR T-cell therapy. CMS does not believe enough data is available to make a change at this time. However, CMS has finalized the continuation of CAR-T cell therapy being eligible for new technology and add-on payments for FY 2020.

MDC 1: Diseases and Disorders of the Nervous System

Carotid Artery Stent Procedures

Current logic for case assignment to MS-DRGs 034, 035, and 036 (Carotid Artery Stent Procedures with MCC, with CC, and without CC/MCC respectively) “is comprised of two lists of logic that include procedure codes for operating room (O.R.) procedures involving dilation of a carotid artery (common, internal or external) with intraluminal device(s).”

CMS identified 46 ICD-10-PCS procedures codes in the second list that do not describe dilation of a carotid artery with intraluminal device. CMS finalized the proposal to remove these 46 codes from MS-DRGs 034, 035 and 036.

These 46 ICD-10-PCS codes are also assigned to MS-DRGs 037, 038, and 039 (Extracranial Procedures with MCC, with CC, and without CC/MCC, respectively.) Therefore, CMS also examined claims data for this MS-DRG group and finalized their proposals to:

• Remove 96 ICD-10-PCS procedure codes describing dilation of a carotid artery with an intraluminal device from the logic for MS-DRG group 037-038 and 039,
• Reassign 6 ICD-10-PCS procedure codes describing dilation of a carotid artery with an intraluminal device from MS-DRG group 037, 038 and 039 to MS-DRG group 034, 035, and 036,
• Delete 48 procedure codes from MS-DRGs 037, 038, and 039 that include the qualifier term “bifurcation;” and
• Combining all procedure codes identifying a carotid artery stent procedure within MS-DRGs 034, 035, and 036 into one list entitled “Operating Room Procedures” to better reflect the definition of the MS-DRGs.

MDC 4: Diseases and Disorders of the Respiratory System

Pulmonary Embolism

A request was made to reassign the following three ICD-10-CM diagnosis codes for Pulmonary Embolism (PE) with acute core pulmonale from MS-DRG 176 (PE without MCC) to MS-DRG 175 (PE with MCC):

• I26.01 – Septic pulmonary embolism with acute cor pulmonale,
• I26.02 – Saddle embolus of pulmonary artery with acute cor pulmonale, and
• I26.09 – Other pulmonary embolism with acute cor pulmonale.

The requestor noted with the FY 2019 IPPS Final Rule special logic change where a Principal Diagnosis could no longer be its own CC or MCC this resulted in these three codes being assigned to MS-DRG 176 when no other MCC is present. The requestor stated MS-DRG 176 does not appropriately account for cost and resource utilization associated with these cases.

CMS claims analysis supported the requestor’s statement about cost and resource utilization. CMS has finalized their proposals to:

• Reassign cases reporting diagnosis codes I26.01, I26.02 and I26.09 to MS-DRG 175, and
• Revise the MS-DRG 175 title to “Pulmonary Embolism with MCC or Acute Cor Pulmonale.”

The difference in relative weight (RW) and Geometric Mean Length of Stay (GMLOS) are reflected in the following table.

‍ MDC 5: Diseases and Disorders of the Circulatory System

Transcatheter Mitral Valve Repair (TMVR) with Implant

CMS received a request to modify the current MS-DRG assignment for TMVR with implant procedures (MS-DRG 228 and 229: Other Cardiothoracic Procedures with MCC and without MCC, respectively). The requestor believed that TMVR is more similar to the replacement procedures in MS-DRGs 266 and 267 compared to other procedures currently assigned to MS-DRGs 228 and 229 and “noted that both TMVR procedures and endovascular cardiac valve replacements use a percutaneous approach, treat cardiac valves, and use an implanted device for purposes of improving the function of the specified valve.”

In the Proposed Rule CMS indicated “Our clinical advisors continue to believe that transcatheter cardiac valve repair procedures are not the same as a transcatheter (endovascular) cardiac valve replacement.

However, they agree with the requestor and, based on our data analysis, that these procedures are more clinically coherent in that they also describe endovascular cardiac valve interventions with implants and are similar in terms of average length of stay and average costs to cases in MS-DRGs 266 and 267 when compared to other procedures in their current MS-DRG assignment. For these reasons, our clinical advisors agree that we should propose to reassign the endovascular cardiac valve repair procedures (supplement procedures)…to the endovascular cardiac valve replacement MS-DRGs.”

CMS finalized the following proposals:

• Modify the structure of MS-DRGs 266 and 267 by reassigning the procedure codes describing transcatheter cardiac valve repair (supplement) procedure,
• Revise the title of MS-DRG 266 from “Endovascular Cardiac Valve Replacement with MCC” to “Endovascular Cardiac Valve Replacement and Supplement Procedures with MCC,”
• Revise the title of MS-DRG 267 from “Endovascular Cardiac Valve Replacement without MCC” to “Endovascular Cardiac Valve Replacement and Supplement Procedure without MCC,”
• Create two new MS-DRGs with a two-way severity split for the remaining (non-supplement) transcatheter cardiac valves.
• MS-DRG 319 (Other Endovascular Cardiac Valve Procedures with MCC), and
• MS-DRG 320 (Other Endovascular Cardiac Valve Procedures without MCC).

Pacemaker Leads

CMS noted that ICD-10-PCS procedure code 02H60JZ (Insertion of pacemaker lead into right atrium, open approach) was inadvertently omitted from the GROUPER logic for MS-DRGs 260, 261, and 262. They finalized adding this procedure code to the list of Non-O.R. procedures that would impact MS-DRGs 260, 261, and 262 when reported as a stand-alone procedure code.

MDC 8: Diseases and Disorders of the Musculoskeletal System and Connective Tissue

Knee Procedures with Principal Diagnosis of Infection

In FY 2019 ICD-10-CM diagnosis codes M00.9 (Pyogenic arthritis, unspecified) and A54.42 (Gonococcal arthritis) grouped to MS-DRGs 488 and 489 (Knee Procedures without Principal Diagnosis of Infection with and without CC/MCC, respectively) when a knee procedure is reported on the claim.

CMS received a request to add these two codes to the list of principal diagnoses for MS-DRGs 485, 486, 487 (Knee Procedure with Principal Diagnosis of Infection with MCC, with CC, and without CC/MCC, respectively).  

CMS finalized the following:

• Add both codes to the list of principal diagnosis codes for MS-DRGs 485, 486 and 487,
• Add 10 additional ICD-10-CM diagnosis codes specific to the knee and describing an infection; and
• Remove 8 ICD-10-CM diagnosis codes from the list of principal diagnosis for MS-DRG 485, 486 and 487 as they do not describe an infection of the knee.

Scoliosis: Neuromuscular and Secondary Scoliosis and Kyphosis

Requests were made to add ICD-10-CM diagnosis codes describing neuromuscular scoliosis, secondary scoliosis and secondary kyphosis to the list of principal diagnosis codes for MS-DRGs 456, 457, and 458 (Spinal Fusion except Cervical with Spinal Curvature or Malignancy or Infection or Extensive Fusions with MCC, with CC, without CC/MCC, respectively).

CMS finalized their proposals to:

• Add 5 codes describing neuromuscular scoliosis and 8 codes describing secondary scoliosis and secondary kyphosis to the list of principal diagnosis codes for MS-DRGs 456, 457, and 458; and
• Remove 34 ICD-10-CM diagnosis codes describing conditions involving the cervical region from MS-DRGs 456, 457, and 458.

MDC 11: Diseases and Disorders of the Kidney and Urinary Tract

Extracorporeal Shock Wave Lithotripsy (ESWL)

Data analysis revealed a steady decline in inpatient cases reporting urinary stones and an ESWL procedure over the past five years. CMS indicated in the proposed rule that due to an ESWL procedure being a Non-O.R. procedure and the decreased usage of this procedure in the inpatient setting, clinical advisors believe there is no longer a reason to subdivide the MS-DRGs for urinary stones (MS-DRGs 691 &692, and 693 & 694) based on ESWL procedures.

• Delete MS-DRGs 691 and 692 (Urinary Stones with ESW Lithotripsy with CC/MCC and without CC/MCC respectively); and
• Revise the MS-DRG title for MS-DRGs 693 and 694 from “Urinary Stones without ESW Lithotripsy with MCC” and “without MCC”, respectively to “Urinary Stones with MCC” and “Urinary Stones without MCC.”

MDC 12: Diseases and Disorders of the Male Reproductive System

In FY 2019, four ICD-10-CM diagnosis codes (R93.811, R93.812, R93.813, and R93.819) describing body parts with male anatomy grouped to in MS-DRGs 302 and 303 (Atherosclerosis with MCC and without MCC, respectively) in MDC 5 (Diseases and Disorders of the Circulatory System).

Based on a request and claims data analysis, CMS finalized the reassignment of these four codes from MDC 5 in MS-DRGs 302 and 303 to MS-DRGs 729 and 730 (Other Male Reproductive System Diagnosis with CC/MCC and without CC/MCC, respectively) in MDC 12.

MDC 14: Pregnancy, Childbirth and the Puerperium

Reassignment of Diagnosis Code 099.89 (Other specified Diseases and Conditions complicating pregnancy, childbirth and the puerperium)

CMS finalized their proposal to reclassify ICD-10-CM diagnosis code 099.89 (Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium) from a postpartum condition to an antepartum condition.

Coding logic will now assign a case with an O.R. procedure and this code to MS-DRGs 817, 818, or 819 (Other Antepartum Diagnoses with O.R. Procedure with MCC, with CC, and without CC/MCC, respectively). When no O.R. procedure is reported on the claim, the logic will assign the case to MS-DRGs 831, 832, and 833 (Other Antepartum Diagnoses without O.R. Procedure with MCC, with CC, and without CC/MCC, respectively).

MDC 23: Factors Influencing Health Status and Other Contacts with Health Services

Assignment of Diagnosis Code R93.89 (Abnormal finding on diagnostic imaging of other specified body structures)

There was a request to reassign ICD-10-CM diagnosis code R93.89 from MS-DRGs 302 and 303 (Atherosclerosis with MCC and without MCC, respectively) in the Circulatory MDC 5 to MDC 23.

CMS finalized their proposal to reassign this diagnosis code to MS-DRGs 947 and 948 (Signs and Symptoms with MCC and without MCC, respectively).

Review of Procedure Codes in MS-DRGS 981 through 983 and 987 through 989

Adding Procedures Codes Currently Grouping to MS-DRGS 981 – 983 and 987 – 989 into MDCs

Annually, CMS conducts a review of procedures resulting in assignment to the O.R. and non-extensive O.R. Procedures Unrelated to Principal Diagnosis MS-DRG Groups (981-983 and 987-989). This review is done on the basis of volume, by procedure, to see if it is more appropriate to move a procedure to a surgical MS-DRG for the MDC where the Principal Diagnosis falls.

Several proposals were made and finalized for FY 2020 to move diagnosis and procedure codes back into a specific MDC including:

• Gastrointestinal stromal tumors (GIST),
• Peritoneal dialysis catheter complications codes,
• Bone excision with pressure ulcers codes,
• Lower extremity muscle and tendon excision codes,
• Insertion of feeding device code,
• Basilic vein reposition in chronic kidney disease codes; and
• Colon Resection with Fistula code 0DTN0ZZ.

You can access the Final Rule and related tables on the FY 2020 IPPS Final Rule Home Page . 

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Diagnosis-Related Group (DRG)

• First Online: 20 July 2023

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• Peter L. Elkin 2 &
• Steven H. Brown 3 , 4  

Part of the book series: Health Informatics ((HI))

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Prospective payment rates based on diagnosis-related groups (DRGs) have been established as the basis of Medicare’s hospital reimbursement system. The DRGs are a patient classification scheme, which provides a means of relating the type of patients a hospital treats (i.e., its case mix) to the costs incurred by the hospital. The design and development of the DRGs began in the late 1960s at Yale University. The initial motivation for developing the DRGs was to create an effective framework for monitoring the quality of care and the utilization of services in a hospital setting. The first large-scale application of the DRGs was in the late 1970s in the State of New Jersey. The New Jersey State Department of Health used DRGs as the basis of a prospective payment system in which hospitals were reimbursed a fixed DRG-specific amount for each patient treated. In 1982, the Tax Equity and Fiscal Responsibility Act modified Section 223 Medicare hospital reimbursement limits to include a case mix adjustment based on DRGs. In 1983, Congress amended the Social Security Act to include a national DRG-based hospital prospective payment system for all Medicare patients.

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Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA

Peter L. Elkin

Knowledge Based Systems, Department of Veterans Affairs, Washington, DC, USA

Steven H. Brown

Department of Biomedical Informatics, Vanderbilt University, Nashville, TN, USA

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Elkin, P.L., Brown, S.H. (2023). Diagnosis-Related Group (DRG). In: Elkin, P.L. (eds) Terminology, Ontology and their Implementations . Health Informatics. Springer, Cham. https://doi.org/10.1007/978-3-031-11039-9_16

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Inpatient Coding System and Opportunities for Documentation Optimization: An Interactive Session for Internal Medicine Residents

Lindsey jordan gay.

1 Assistant Professor, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Department of Veterans Affairs Medical Center

2 Associate Professor, Department of Medicine, Baylor College of Medicine

3 Fourth-Year Medical Student, Baylor College of Medicine

Glynda Raynaldo

Associated data.

• MS-DRG Components and Glossary.pdf
• Documentation Improvement Tip Sheet.pdf
• Facilitator Guide.docx
• Presession Survey.docx
• Inpatient Coding Summary.pptx
• Clinical Vignettes and Documentation.pptx
• Score Sheet.docx
• Postsession Survey.docx

All appendices are peer reviewed as integral parts of the Original Publication.

Introduction

The Inpatient Prospective Payment System, the framework for categorization of admissions, is based upon physician documentation leading to International Classification of Diseases, Tenth Revision code generation and Medical Severity Diagnosis-Related Group (MS-DRG) assignment. In this curriculum, we introduced internal medicine residents to this inpatient coding framework and its effects on hospital quality metrics and reimbursement. We focused on educating learners about the importance of physicians being proficient in providing thorough and specific clinical documentation to produce appropriate DRG assignment.

Internal medicine residents participated in a 90-minute session that introduced the basic framework of inpatient coding, discussed effects of physician documentation on hospital quality metrics and reimbursement, and provided tips on opportunities for documentation improvement. In an interactive learning activity, residents were presented with clinical vignettes and earned reimbursement based on their documentation of appropriate diagnoses. Each scenario was followed by clinical definitions and actionable documentation recommendations for common diagnoses. Materials included a PowerPoint presentation, clinical vignettes, sample teaching points, and a rubric to calculate estimated reimbursement.

Prior to the session, 38% of learners were confident in their understanding of how documentation affects hospital reimbursement, which improved to 90% postsession. Learners reported improvement in their knowledge of documentation requirements for all targeted diagnoses.

This interactive curriculum improved resident knowledge of the inpatient coding system and documentation requirements for common diagnoses and addressed a deficiency in residency education on a topic of significant importance for the success of hospital systems.

Educational Objectives

By the end of this activity, learners will be able to:

• 1. Articulate the importance of optimal clinical documentation during the care of the hospitalized patient.
• 2. Distinguish the basic components of the Medical Severity Diagnosis-Related Group (MS-DRG).
• 3. Describe the quality metrics derived from MS-DRG selection.
• 4. Analyze how variations in medical documentation affect hospital quality metrics and reimbursement.
• 5. Recognize the clinical indicators necessary to support the diagnoses of common conditions in hospitalized patients.

In 1984, the Centers for Medicare & Medicaid Services released the framework for the Inpatient Prospective Payment System (IPPS) to classify hospital admissions and set reimbursement rates for facilities. 1 While this system has undergone many iterations and updates over the years, it remains the primary method through which hospitalizations are categorized. In this system, Medical Severity Diagnosis-Related Groups (MS-DRGs) collate admissions based on similar conditions to assign expected resource utilization. 2 This classification has numerous implications for hospital systems’ quality metrics, including case mix index (CMI), mortality ratios, and expected length of stay. This assignment is also vital for the reimbursement and revenue streams of hospital systems. 3 The selection of MS-DRGs is dependent upon the assignment of International Classification of Diseases, Tenth Revision codes, 2 which are populated based upon a physician's documentation. With this in mind, thorough and specific physician documentation is vital for appropriate coding, which then drives quality metrics and reimbursement.

In teaching hospitals across the country, resident trainees provide the bulk of clinical documentation in the inpatient setting. The ACGME has recognized in its core competencies that interprofessional communication skills and systems-based practices are vital domains of competence for residency training programs. Key competencies within these domains are “effective exchange of information,” maintenance of comprehensive medical records, and “awareness and responsiveness to the larger health care system,” which relate directly to clinical documentation skills. 4 Despite this, there is limited curricular focus in graduate medical education on clinical documentation and subsequent coding. Multiple studies have shown that residents feel ill prepared in this regard. 5 – 9 A study of surgical residents found that 85% felt they were novices at coding and billing and 82% stated they had not received adequate training. 6

When coding and clinical documentation are included in residency education, they are overwhelmingly focused on physician reimbursement. There are numerous studies in both the outpatient and inpatient settings across multiple specialties showing that educational programs aimed at Current Procedural Terminology (CPT) and Evaluation and Management (E&M) codes have been successful in increasing resident comfort with these concepts 6 – 9 and increasing physician billable income. 10 While the data are less robust, studies have shown that educational programs targeting residents in surgical subspecialties and internal medicine focused on facility reimbursement and clinical documentation in hospitalized patients have resulted in improvements in facility reimbursement and quality metrics. 11 – 17 These education programs have shown significant improvements in facility CMI, 10 – 14 , 16 complication/comorbidity (CC) code capture, 11 , 15 , 16 risk-adjusted length of stay, 12 – 14 risk-adjusted mortality, 11 and reimbursement. 13 , 15

MedEdPORTAL has published curricula on improvement in documentation and coding for physician reimbursement and on CPT and E&M codes for internal medicine and emergency medicine residents. 6 – 8 , 18 – 20 These curricula use multiple teaching strategies, including didactics, self-paced online modules, small-group review of sample notes, and simulated patient encounters in the electronic medical record. Our curriculum is novel in that it is the first published curriculum for residents on the inpatient coding system that is used to determine hospital facility reimbursement and quality metrics. It is also the only curriculum that identifies opportunities for documentation improvement and provides clinical criteria for conditions commonly encountered in the inpatient setting. The gamification aspect of our documentation and coding curriculum is also a novel aspect distinguishing it from currently published curricula. This curriculum is targeted for internal medicine residents at all levels of training but could be easily adapted for internal medicine fellows or trainees from other medical specialties.

We created a 90-minute interactive inpatient coding and documentation improvement session for internal medicine PGY 1–3 residents. Three of the authors of this publication were experienced hospitalists with prior knowledge of inpatient documentation and coding. The authors had been involved with the hospital's clinical documentation integrity (CDI) department to educate hospital staff and trainees, as well as with the facilitation of meetings between attending physicians, residents, and coding staff. It would be helpful for future course facilitators to have some baseline knowledge about clinical documentation improvement and the basic structure of the inpatient coding system. For facilitators who are less knowledgeable regarding the system, we have created an overview schematic of the components of MS-DRG assignment along with a glossary of important terms ( Appendix A ). A review of this information along with the other curricular content (including the provided teaching notes) will provide the baseline knowledge necessary to successfully lead the session. The Association of Clinical Documentation Integrity Specialists (ACDIS), a national organization that provides educational material and a physician boot camp related to clinical documentation, may be another useful resource. We advise future facilitators to partner with the coding departments at their local hospitals for an additional source of expertise and to ensure the content is in line with their institution's guidelines. Six months prior to this session, the CDI department at one of our affiliate hospitals distributed a poster to trainees with high-yield documentation tips and a listing of diagnoses considered major CCs; this poster was created by two of the authors of this publication ( Appendix B ).

We met eight times to develop the curriculum. We brainstormed the optimal strategies to teach residents the basics of inpatient coding and provide documentation tips for high-yield diagnoses. We established the 10 most high-yield opportunities for documentation optimization and developed clinical vignettes to demonstrate the specific diagnoses and clinical criteria. These were made into two PowerPoint presentations that were used in the session. For each clinical case, we formulated a rubric of likely diagnoses that the learners might select and determined the MS-DRG, case weight, expected length of stay, and estimated reimbursement for each option. We then used an online platform, Formative, to set up an audience response system to use during the session. This platform allowed for free-response entry of principal and secondary diagnoses for each clinical vignette, but any similar platform could be used. Pre- and postsession assessments were developed to evaluate residents' self-reported knowledge regarding inpatient coding fundamentals and their knowledge of documentation requirements for various diagnoses. The evaluation of the curriculum was approved by the Baylor College of Medicine Institutional Review Board.

Implementation

The interactive curriculum was presented to internal medicine residents during their weekly didactic session over a period of 8 weeks. The session could be led by one facilitator with up to 20 residents, ideally with variable levels of training. For the small-group portions of the curriculum, it was ideal to have up to four small groups with no more than five learners in each group to maintain active participation by all. We provide full details for implementation in the facilitator guide ( Appendix C ).

Equipment and delivery

The equipment required to implement this curriculum included a computer connected to an audiovisual system, an online audience response platform, and internet or cellular connectivity for the audience. If internet connectivity was not available for the audience, the facilitator could use flip charts for individuals to write out diagnoses instead of an online system. Additionally, if content needed to be delivered remotely, a teleconferencing platform could be employed with the use of a breakout room feature to allow for small-group collaboration, with a return to the large group for report-out and didactic content.

Presession survey—5 minutes

Participants first completed a paper presession survey ( Appendix D ) that assessed their confidence with the basics of inpatient coding and documentation. We evaluated learners’ self-reported knowledge on appropriate documentation requirements for specific diagnoses including respiratory failure, sepsis, heart failure, functional quadriplegia, pneumonia, nutritional status, anemia, altered mental status, and acute kidney injury/acute tubular necrosis.

Inpatient coding summary—15 minutes

Facilitators then presented a PowerPoint to introduce IPPS, the MS-DRG system, and values assigned based upon DRG assignment ( Appendix E ). Facilitators discussed how these values affect hospital quality metrics including CMI, length of stay, mortality, and reimbursement. Teaching scripts and key points were included in the notes section of the PowerPoint.

Team assignments—5 minutes

Facilitators next divided residents into small groups with equal distribution based upon level of training. Small groups selected a team name and logged into the online response system (or gathered at the prepared flip chart for each group).

Clinical vignettes and documentation pearls—60 minutes

After all small groups were assembled, facilitators presented the seven clinical case vignettes ( Appendix F ) to all small groups. At the end of each case, teams documented their principal and secondary diagnoses into the online system. The facilitators then displayed each group's response for the entire audience to see and reviewed the assigned DRG, case weight, length of stay, and reimbursement associated with the various potential principal and secondary diagnoses. Facilitators used the rubric to assign reimbursement to each team based on the selected diagnoses ( Appendix G ). If the team selected a diagnosis that was not supported by clinical data, the facilitators declined the claim, and the team was fined $1,000. Facilitators also provided clinical definitions and actionable documentation tips for the targeted diagnoses.

Wrap-up and postsession survey—5 minutes

At the end of the session, learners completed a paper postsession survey to reassess knowledge and confidence with inpatient coding and documentation requirements for targeted diagnoses and to offer feedback on the content delivery method ( Appendix H ). While learners completed this survey, the facilitators calculated each team's total reimbursement using the rubric in Appendix C and announced the winning team. We provided all learners with a copy of the documentation improvement tip sheet at the conclusion of the session for future reference ( Appendix B ).

We compared the anonymous pre- and postsession surveys to assess significance of the change in learner confidence using the chi-square test. We used the Wilcoxon test for unpaired data to analyze changes in learners’ self-reported knowledge of appropriate documentation of the diagnoses targeted in the session. Learners self-reported their knowledge on a 5-point Likert scale (1 = very poor, 5 = excellent ).

A total of 67 PGY 1–3 internal medicine residents participated in the educational session from June to August 2017. Of participating residents, 66 completed the presession survey, and 67 completed the postcurriculum survey. One resident arrived late to the session and only completed the postcurriculum survey. Since the surveys were anonymous, we were unable to exclude the late-arriving resident's postcurriculum survey. Prior to this curriculum, 13% of residents stated that they had never had a lecture on coding, 59% had received one lecture on coding, and 27% had received two lectures on coding. Despite some residents having prior exposure to coding and documentation, confidence in self-reported knowledge of coding and documentation, DRGs, case severity index, and understanding how documentation affects hospital reimbursement all improved significantly (  p < .05; Figure 1 ). Furthermore, 86% of the residents either agreed or strongly agreed on the postsession survey that this information would be important for their residency training and education.

Self-reported knowledge of appropriate documentation, assessed on 5-point Likert scale (1 = very poor, 5 = excellent ), significantly improved for all nine diagnoses covered in the session (  p < .05). Residents reported the most improvement for nutrition (2.6 to 3.7), altered mental status (2.7 to 3.8), and acute kidney injury/acute tubular necrosis (2.8 to 3.9; Figure 2 ). In addition, postsession survey comments indicated that learners enjoyed the interactive elements and felt they were an effective method for delivery of the curriculum. Learner comments included the following:

• • “Great way to teach this topic; reinforced the important aspects of how to code.”
• • “Was fun seeing how much hospitals would earn based on documentation.”
• • “Interactive slides are the way to go!”
• • “Awesome teaching modality; makes an important topic fun and engaging.”
• • “Nice range of cases of commonly encountered cases.”
• • “This was a very useful and informative presentation about coding.”
• • “Really well designed lecture with interactive components.”
• • “Very helpful! Good to know the nuances for appropriate documentation.”
• • “Fun interactive lecture.”
• • “Enjoyed the course and interactive nature.”
• • “Excellent talk, engaging and helpful.”
• • “Great lecture, good interactivity.”

Our educational session to introduce medical residents to the basics of inpatient hospital reimbursement was novel, innovative, and well received. We were able to improve residents’ self-reported knowledge of how hospitals are reimbursed for inpatient care and how physician documentation is vital to optimization of quality metrics and facility reimbursement. At the conclusion of the session, learners reported increased knowledge of the inpatient coding process and the documentation requirements for common high-yield diagnoses. Residents felt that this material was important to their medical training, and they enjoyed the interactive and gamification components of this curriculum.

Feedback from leadership at our affiliate institution about how documentation practices of our trainees were not meeting the needs of the hospital system created the initial impetus to develop and implement this curriculum. We knew very little regarding the inpatient coding system and had to embark on extensive self-directed learning to become subject matter experts. Through the resources provided in this publication, we were able to understand the structure and importance of the inpatient coding system and develop this session. It is likely that other institutions face similar challenges with resident documentation and a lack of faculty with expertise in this area. For institutions wishing to implement this curriculum, it may be necessary to recruit physician champions in this field. The materials offered in this curriculum are meant to provide the sufficient baseline knowledge necessary for facilitators without experience to successfully lead this session. Facilitators may want to get involved with national organizations like ACDIS that provide continuing education to maintain and expand their knowledge base. We also advise facilitators to partner with coding and documentation staff at their hospitals. However, we feel strongly that involvement of core teaching faculty is critical for obtaining additional buy-in from trainees.

A major limitation of this study is that we depended on self-reported outcomes of knowledge gain instead of objective assessment. Following implementation of this curriculum, we recommend longitudinal assessment of learners’ knowledge retention and continual feedback for documentation improvement. We currently do this informally during coding huddles where trainees join two of the authors of this curriculum serving as physician advisors, along with attending physicians and coding staff, to review clinical documentation for active inpatients. This setting provides an opportunity for real-world and real-time feedback on individual trainees’ performance and suggestions for documentation clarification and improvement. Another caveat is that through CDI involvement at our partner hospitals, many of our learners had received some exposure to inpatient coding and documentation improvement prior to our session, which may not be the case in all training programs. Despite the baseline exposure of our learners, we were able to show significant self-reported improvement in knowledge. Therefore, we feel that this can be a stand-alone session for trainees who do not have prior coding or documentation experience.

We learned many lessons while implementing a clinical documentation optimization session in our program. In initial attempts to deliver this content to learners, we focused on the diagnostic criteria for each diagnosis and often faced resistance since trainees did not feel that this was important for patient care. When we taught trainees why their documentation practices were vital to their hospital systems, we were able to obtain more engagement. This led us to alter our approach and develop this session, which has the dual focus of providing education on clinical indicators for diagnoses and demonstrating how documentation of these diagnoses affects hospital reimbursement and quality metrics. Some residents expressed concerns regarding the potential for fraud and the legal and ethical ramifications regarding documentation optimization. To address this, we intentionally included cases where a diagnosis might be documented without appropriate clinical indicators and demonstrated how this would result in claim denial and penalty. We plan to expand this in future iterations of this curriculum, with an added focus on the differentiation between appropriate coding and the potential for overcoding and fraud. Another lesson that we learned was the need for continual updates and modifications to the curriculum as clinical definitions and coding regulations change. Lastly, this is a very broad and nonintuitive process for physicians, so frequent reeducation and repetitive exposure to this material are crucial for retention and sustainability. Potential opportunities for additional integration into training programs include real-time feedback on clinical documentation and documentation feedback during regularly scheduled clinical case conferences.

Medical residents spend a substantial amount of time documenting in the medical record but are not always aware of the diverse implications and utilizations of these records. Educating trainees on these implications and opportunities for optimization will make them more likely to engage in educational sessions and integrate this into their daily and future practice. With this interactive curriculum, we were able to improve residents’ confidence and knowledge of the inpatient coding system and documentation requirements of common inpatient diagnoses. Multiple studies have shown that educational programs with this focus can have significant effects on quality metrics and reimbursement at facilities where residents train. With this in mind, hospital systems should be willing and excited to partner with training programs and provide resources for implementation. This novel curriculum addresses a current deficiency in residency education on a topic of significant importance for hospital systems.

Disclosures

None to report.

Funding/Support

Ethical approval.

The Baylor College of Medicine and Affiliated Hospitals Institutional Review Board approved this project.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the United States government, or Baylor College of Medicine.