Coding Case Study 1

Coding Case Study 1

Problem Statement

OK based hospital identified their CMI value was trending upto 0.9, for the last quarter. From their basic research, they realized a huge revenue was incurred as an impact on this CMI value.

Project Objective

To increase the case mix index value of IP DRG from 0.9 to 1.2 in 45 days.

Root Cause Analysis

After a detailed study, we identified unspecified diagnosis were coded from the medical record without querying the provider in order to figure out the specificity. This had an impact on the CMI value which resulted in reduced reimbursement.

Solutions Provided

Presented the different possible specificities of the DX Codes and educated the provider on the importance of the documentation for higher DRG value.

This way, most of the diagnosis in CC goes to MCC which automatically increases the weightage of the DRG value, and this results in higher reimbursement.

Results Shown

  • Improved the CMI value from 0.9 to 1.4 in the initial 45 days
  • Increased the reimbursement up to $262K per month (nearing 35%) with our coding recommendations
  • Assisted providers with documentation improvement