LIGGETTJEFFDRGAuditResults

TCC HOSPITAL AUDIT RESULTS FOR DRG ACCURACY JEFF LIGGETT Overview An internal DRG audit of cases coded to MS-DRG 195 Simple Pneumonia without an MCC/CC is being conducted. It appears as though DRG 195 was one of many that appeared on the most recent CMS Comprehensive Error Rate Testing (CERT) Program report with upcoding errors, overpayments, and other improper payments. The purpose of an audit is to determine if the entity being reviewed is complying with the requirements. If the entity is not in compliance, then corrective action must be taken to bring it into compliance. This is called remediation. Remediation is taking steps to correct problems found during an audit. Audit Methods The type of audit being conducted is a Statistical Audit Sampling. Statistical audit sampling involves a sampling approach where the auditor utilizes statistical methods such as random sampling to select items to be verified. Random sampling is used when there are many items or transactions on record. Consider a company with more than 100 inventory transactions on its records. Using statistical sampling is recommended due to the high number of transactions. The primary advantage of using a statistical sampling approach is that risk is objectively determined. It is a widely accepted methodology in an audit or other review of healthcare claims to identify improper payment amounts. When performed in a valid scientific manner, statistical sampling permits the auditor to estimate overpayments in a universe of claims that may be too voluminous or complex to permit a claim-by-claim review. Statistical sampling saves the time and expense of reviewing the entire universe of claims by allowing a small sample of claims to be analyzed. Audit Findings Based on the findings, the distribution of records observed is varied. The audit procedure that was employed was probably efficient in locating coding problems and producing suggestions for how to make things better. However, it is not apparent how frequently these audits are carried out or how many different cases are examined. The sample size used was very small compared to the large total number of charts. The sample size should have been 10% of the total which would have been around 62 charts. This would have been a suitable number to offer accurate results. The 7 coders were given varying number of charts to audit. This was inappropriate since there cannot be a proper evaluation of the results gotten by each of them. They should have been given around equal samples so as to identify the pattern.