The Fair Play Advantage: Navigating the DRG System with Ethical Coding for Optimal Performance - strategies to Identifying and Mitigating Gaming and Undercoding
Jana Wahl a, Vesna Mesojednik b, Simon Zupan b, Marko Jug b
Background
The implementation of an updated DRG version in a large university hospital presents challenges, including the potential for gaming and undercoding.
Addressing gaming and undercoding requires a multi-pronged approach: continuous data monitoring, strong leadership, inter-professional communication, comprehensive coder training, and knowledge sharing.
Lack of knowledge about the updated DRG systems and details of potential co-payments in a fully implemented system, as well as insufficient knowledge among coders, can lead to unintentional errors and potentially contribute to undercoding, necessitating the creation of a core coding group.
This paper highlights valuable strategies and key learnings from a benchmarking exercise as part of an ongoing, coordinated effort in a university hospital to achieve accurate coding and optimized financial performance under the updated ArDRG system.
Methods
Public data available at ZZZS (National Health Insurance Fund) were obtained to compare DRG structures by adjacent DRGs for years 2019, 2022, and 2023, excluding 2020 and 2021 due to pandemics.
DRG groups were analyzed for UKCL and benchmarked against other hospitals.
The DRGs with greater differences among UKCL and other hospitals were identified and analyzed.
Results
Analysis of benchmarking data revealed potential signs of gaming and/or undercoding.
Table 1: DRG structure for University Clinical Center Ljubljana for years 2019, 2022, and 2023. A full table with data from other hospitals is going to be shown in the final paper.
Comparing 2019 (ICD10-AM v4), and 2023 (ICD-10 AM v10) in UKCL in 2023 the proportion of the structure in the group of the severe adjacent DRGs A and B increases, while the overall average cost weight decreases.
The structure of DRGs varies by type of hospital, in some cases contrary to what is expected.
Tertiary hospitals UKCL and UKCM have a roughly similar structure of difficulty.
In 2023, with the updated version an increase in the proportion of patients in the DRG group with severity A-severe (extensive) complications, B-moderate complications, and C-no complications was observed at UKCL, mainly due to the removal of some SPP groups with the Z ending.
Compared to the same period in 2022, the group A weight structure in UKCL has increased from 29.82 to 32.46, and when comparing the patient structure, from 17.55 to 22.75.
At the same time, it should be noted that in this group (A) the average cost weight per case of UKCL has decreased from 3.14 to 2.61 and consequently the average weight of all DRGs has also decreased from 1.85 in 2022 to 1.83 in 2023.
UKCM similarly has a higher proportion in difficulty A in both the patient structure (27.93) and the weight structure (33.58) compared to UKCL in the period 1-11 2023.
Both tertiary hospitals have the highest proportion of patients in difficulty B, UKCL 53.58 and UKCM 46.54.
In terms of the severity structure, some general or secondary hospitals stand out, with a higher proportion of patients in adjacent group A (i.e. the most severe patients) than in both University Medical Centers, up to 42%, and even more than 50% when looking at the weights.With regard to the latter, we believe that there are few possible explanations for these discrepancies. As other available data suggests that UKCL and UKCM treat the most complicated patients in the country, it may be necessary to conduct an external audit as well as an internal audit at UKCL to verify the accuracy of coding and identify any potential undercoding.
Conclusion
Identifying and Mitigating Gaming and Undercoding is critical for a fair DRG play.
An initial lack of knowledge of the new system was identified as a challenge requiring a coder training initiative using online education and peer support. Leadership and engagement with different professional cultures emerge as critical factors in promoting ethical coding in hospitals. Tackling gaming and undercoding requires a multi-pronged approach with
- Ongoing monitoring and analysis of benchmarking data
- Strong leadership commitment to ethical coding practices.
- Effective communication and collaboration across professional cultures.
- Comprehensive training and support for coders on the new DRG system.
- Promoting knowledge sharing and continuous learning.
a University Clinical Center, Ljubljana, Slovenia, Slovenia
b University Medical Center Ljubljana, Slovenia, Slovenia