Guest Post: Who is driving the DRG bus?

by Karen Newhouser, RN, BSN, CCM, CCDS

I was excited to attend the ICD-10 for CDI Boot Camp presented by Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., during the pre-conference session in Nashville this year.

If you have the opportunity, I urge you to attend. ICD-10 will be here before we know it. Think about it. Doesn’t it seem like only last week we began writing ‘2013’? The transition to ICD-10 will be a huge task and the more prepared you are, the better it will be for your career.

In addition to the wealth of knowledge Ericson offered on preparing for ICD-10 implementation, she injected pearls of wisdom to enable us to hit the ground running as soon as we all got back to work. One that piquews my interest was a pearl about choosing the most appropriate principal diagnosis.

Collectively as a profession, we are competent in CC/MCC capture rates, maximizing the severity of illness and risk of mortality, and decreasing the mortality index by assisting providers with precise documentation of the patient encounter. Yet, all of the above does no good if we don’t get the principal diagnosis right.

One of my favorite books is Good to Great by Jim Collins. In order to take a company (or a CDI program) from good to great, Collins says to identify ‘first who, then what.’ The main point is to first get the right people on the bus (and the wrong people off the bus), and then get the right people in the right seats.

Humor me as I relate CDI to a bus (I will call the DRG bus), and then I will use a few of Ericson’s pearls to pull this together with clinical examples.

Let’s think of the people on the bus as the patient’s condition(s) and related codes. This bus can be full or empty of passengers, depending on the situation, but every condition waiting at the bus stop initially needs to get on the bus (POA). Conditions can get off the bus, when the physician rules out a diagnosis, for example, and conditions can get on the bus if new complications arise or conditions are discovered. While these stops are not unusual, the intent is that the number of stops is limited.

When coding, we need to make sure the right codes are placed in the right seats, according to importance and relativity to the driver’s seat. Let’s put the MCCs and CCs close to the front and the E codes and V codes towards the back. The signs and symptoms codes need to sit at the very back, because we don’t want them telling the driver where to go!

Our bus still needs a driver (principal diagnosis). We have to choose carefully because the driver needs to have a license and supporting instructions (documentation) to be able to drive the bus exactly where we want to go.

Several conditions on the bus may appear to be able to drive. But before we choose the driver, we must interview each of them needs to uncover whether they are the right fit for the job. Sometimes the differences are subtle. Sometimes one driver stands alone. Occasionally multiple conditions qualify.

A CDI specialist reviews several items in order to choose the principal diagnosis. One, defined in the Uniform Hospital Discharge Data Set (UHDDS), states that the principal diagnosis is:

“that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

This is often referred to as “What bought the bed?”

But CDI specialists should give some thought to two other questions:

• What kept the patient in the hospital?
• At what point was the patient discharged?

That second one might be new to some CDI specialists and I will try to illustrate it by borrowing those pearls I talked about earlier. Consider two patients, Mrs. Smith and Mr. Jones (fictional, of course, but we all know them well).

Mrs. Smith has a history of congestive heart failure (CHF). We know that CHF is a chronic condition that can occasionally exacerbate and cause Mrs. Smith to seek medical assistance. Mrs. Smith presents with signs and symptoms such as dyspnea, tachypnea, and low oxygen saturation.

The treatment is aimed at relieving the respiratory difficulties. Mrs. Smith is placed on BiPAP^®, given diuretics, and requires constant nursing care beyond the ED. The provider writes an order to admit the patient and documents a diagnosis of CHF exacerbation.

Now, let’s answer a few questions.

1. What is keeping Mrs. Smith in the bed? We used (and are continuing to use) the majority of our resources to correct her respiratory difficulties.

2. When is Mrs. Smith discharged?  When we cure the CHF? Hmm, I think not. You are correct when you say that Mrs. Smith is discharged when her pulmonary status is stabilized. Therefore, if we admitted Mrs. Smith for respiratory difficulties, use the majority of our resources on managing her respiratory difficulties, and discharge Mrs. Smith when her pulmonary state stabilizes, why are we assigning a CHF driver (principal diagnosis) who will take us down the wrong road?

Consider discussing all of the above with the provider and asking him/her for the underlying reason he/she admitted Mrs. Smith. It might just be an acute (on chronic) respiratory failure (relevant clinical indicators assumed, of course).

Now let’s consider Mr. Jones who is brought into the hospital in an altered mental state, a change from his normal (baseline) behavior, according to his family. The physician obtains a full set of vital signs including oxygen saturation, comprehensive metabolic panel, blood count, panculture, and CT of the head.

The urinalysis reveals an infection (UTI). The physician places Mr. Jones on an antibiotic and writes an inpatient admission order. Since most patients do not meet medical necessity as an inpatient admission for a simple UTI, the CDI specialist needs to understand the real reason for the physician’s decision to admit Mr. Jones.  Hint: He does not meet the criteria for sepsis.

Here are the questions again.

1. What is keeping Mr. Jones in the bed? We used (and are continuing to use) the majority of resources on managing his altered mental state.

2. When is Mr. Jones discharged? When his UTI is cleared? Hmmm, I think not. You are correct again when you say that Mr. Jones is discharged when his mental state stabilizes. Therefore, if we admit for an altered mental state, use the majority of our resources on the altered mental state, and discharge when the mental state stabilizes, why are we assigning a UTI driver (principal diagnosis) taking us down the wrong road?

Consider discussing all of the above with the provider and asking him/her the underlying reason Mr. Jones was admitted. It might just be a metabolic encephalopathy (relevant clinical indicators assumed, of course).

It is as important to choose the most appropriate principal diagnosis as it is to choose the appropriate driver of a bus. An inappropriate or incorrect principal diagnosis or bus driver can take you down the wrong road, and you may end up in a place you never intended to go.

The appropriate principal diagnosis (driver) and the right ICD-9 codes (people) in the right order (seats) can make the difference between a good DRG (journey) and a great DRG (journey).

Editor’s Note: Newhouser, at the time of this article's release, was a CDI consultant with MedPartners HIM. Her background in critical care nursing, case management, plus a certificate as a Medical Coding and Billing Specialist has given her the solid foundation to be successful with CDI since 2004. She finds great reward in sharing her expertise and imparting her knowledge through teaching.