INPATIENT DRG VALIDATION
QRConcepts' team of medical professionals can unravel the complex inpatient hospital APR-DRG reimbursement system to ensure that the coding and fees reflect the resources expended in the care of the patient, thereby preventing excess reimbursement to the hospital.
What is the APR-DRG system?
The current APR-DRG (All Patient Refined Diagnostic Related Group) is a mandated complex hospital reimbursement system that focuses on the severity of illness, patient's risk of mortality, and resource intensity to determine a diagnostic group and intensity of service. The goal is to deliver to the hospital a reimbursement rate comparable to the resources expended in the care of the individual patient.
How and why hospitals may optimize rates -
Diagnosis and procedure codes (ICD-9) are used to arrive at the final APR-DRG rate. However, under this system, using one ICD-9 code that is incorrect but similar to the correct ICD-9 code may represent the difference of thousands of dollars in revenue for a hospital on a single case. The financial impact is so great that many hospitals are investing milllions each year outsourcing their medical coding to certified medical coders and auditors in hopes of optimizing their APR-DRG and increasing revenue. Although payers are aware of the fees associated with a facility's assigned APR-DRG, they rarely have the resources necessary to effectively validate and challenge the facility's basis for the coding of those APR-DRGs.
How the QRConcepts team identifies and manages errors in coding and fees -
a. Bill Audit: Each bill's codes will be reviewed and grouped by certified medical coders. Once the APR-DRG group is determined, the hospital fee will be recalculated to confirm or refute price billed;
b. Coding Validation with Bill Audit: Our professional team of RN medical coders will validate the ICD-9 diagnostic and procedural codes assigned against the medical record. They will review the inpatient clinical record, and where codes were assigned incorrectly, without proper clinical support, or have been maximized resulting in increased fees, the team will recode, justify changes, and then re-group and calculate the correct APR-DRG fee.