Room for Improvement: Gastrointestinal Disorders and Payment Errors

The physician is central to deciding whether a patient requires acute inpatient hospital treatment and is also responsible for appropriately documenting the record which permits accurate diagnostic-related grouping (DRG) coding. An area of particular concern both nationally and in New York State has been patients admitted with gastrointestinal (GI) disorders; specifically, DRGs 174 (GI hemorrhage with complication) and 182 (esophagitis, gastroenteritis, and miscellaneous digestive disorders age > 17 with complication comorbidity). A baseline sample of 600 cases from fiscal year (FY) 2006 was selected from 20 hospitals and underwent review for both admission necessity and DRG assignment. The results were disseminated to the hospitals. In addition, hospitals with a >10% error rate were required to implement an improvement plan. A re-measurement sample of 300 cases was taken from FY 2007 for review. The aggregate error rate was 13.3% at baseline and decreased to 8.0% on re-measurement (P < 0.05). Admission denials decreased from 8.0 to 4.7% related primarily to DRG 182. Errors in DRG assignment decreased from 5.7 to 3.3% related primarily to DRG 174. Of note, the greatest improvement in both admission and DRG errors was seen in the hospitals required to implement a formal improvement plan. These data show that a program that includes emphasis on education of physicians on the importance of admission criteria and careful documentation of the record can reduce both inappropriate admissions and improve accuracy of DRG assignment.