Case Mix Issues & Compliance
Case Study 1 (40 Points) Case Mix Issues & Compliance
Domain IV. Revenue Cycle Management
o IV.1. Evaluate assignment of diagnostic and procedural codes and groupings in accordance with official guidelines.o IV.2. Manage components of the revenue cycle.
The purpose of this assignment is to accomplish the objective: Apply the official reporting guidelines for selection and coding of the principal and other diagnoses and procedures. List elements of the revenue cycle and the healthinformation manager’s role in the process.
Required Readings/Resources:
1. Pages 116-127, 43-45, Casto, Ann B and Forrestal, Elizabeth. Principles of Healthcare Reimbursement. Sixth Edition AHIMA
2. Pages 223-234, 282-288, Oachs and Watters. Health Information Management, Concepts, Principles, and Practice, Fifth Edition, 2016, AHIMA.
3. 2019 ICD-10 CM code book ————————————————————————————————————————————————-
Case Scenario:
You manage the coding and revenue cycle integrity office of a small community hospital in your area. For this quarter, the CEO wanted you to focus on increasing the case mix index. The hospital base rate is $7,862. At the time you came onboard, there were three coders; only one of whom was a Certified Coding Specialist (CCS). You began by reviewing the number of MS-DRGs submitted over the past year. The MS-DRG that stood out was: MS-DRG 304, which is hypertension with an MCC. There were 53 submissions of this MS- DRG. As you review the data for the first 10 cases submitted, you began to notice a ‘trend’. Evaluate the data below and identify the issue.
Additional information/instructions: Refer to your ICD-10 CM code book and review the principal diagnosis code for all 10 cases (listed below) as well as all the secondary diagnoses codes. Before answering the questions, you must first read the coding guidelines of Chapter 9: Diseases of the Circulatory System of your ICD-10 CM code book. Evaluate the accuracy of code assignments based on the given information.
Table 1
Chart
Codes submitted
1 I10, J44.9, N18.6, E11.9
2 I10, N18.6, E10.9, E03.9, G47.33
3 I10, G20, I25.10, N18.5
4 I10, F17.210, I70.213, N18.6, E11.9
5 I10, N18.6, I25.5, I25.10
6 I10, E08.22, N18.6
7 I10, E66.01, E03.9, N18.6, F17.210
8 I10, E87.6, J45.909, N18.6
9 I10, E11.9, E66.9, E78.5, N18.5
10 I10, I25.10, N18.6, R33.9, N18.6, E10.9
GR Fall 2019. Case Study Citation: FOLEY, D. (2017). HEALTH INFORMATION MANAGEMENT CASE STUDIES. S.l.: NIELSEN BOOKDATA. Note to students: DO NOT share this course assignment with any person/entity. Please be reminded that you have ‘agreed’ to the BHIS Code of Conduct at the beginning of the course which outlines the Academic Integrity policy of the university (i.e. altering or transmitting without authorization, academic information or records).
Questions:
UNIVERSITY OF ILLINOIS AT CHICAGO
HIM 433 – CODING AND REIMBURSEMENT SYSTEMS
Are assignments of principal diagnosis for all 10 cases correct or incorrect? If correct, support your answer. If incorrect, what is the appropriate principal diagnosis code(s) for all 10 cases and why?
After reviewing all 53 cases in MS-DRG 304, you’ve determined that the principal diagnosis assigned for a total of 46 cases is consistent with your findings in Question 1. Correcting the principal diagnosis for 46 cases will result in reassignment of these cases to a different MS-DRG.
What is the appropriate DRG assignment? (select the appropriate MS-DRG for 46 cases from table below).
Table 2
MS DRG
304
305
308
682
637
MS DRG Description
HYPERTENSION W MCC
HYPERTENSION W/O MCC
CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC RENAL FAILURE W MCC
DIABETES W MCC
Relative Weight 1.0109 0.7199 1.2036 1.5085 1.3813
What is the reimbursement amount of all 53 cases under MS-DRG 304? (show your calculation).
What is the reimbursement amount of the 46 cases with a reassigned MS-DRG? (show your calculation).
What is the financial impact to your healthcare facility as a result of resolving the case mix issues?Will there be a difference to the amount of reimbursement? (show your calculation).
Formula:
Q3 & Q4: Relative weight X hospital base rate X number of cases = Reimbursement Q5 : Reimbursement in Q3 – Reimbursement in Q4 = difference
6. Determine the aspects of a coding compliance plan that need to be addressed following theidentification of coding errors such as those that were found in this exercise and explain why they must betackled.
GR Fall 2019. Case Study Citation: FOLEY, D. (2017). HEALTH INFORMATION MANAGEMENT CASE STUDIES. S.l.: NIELSEN BOOKDATA. Note to students: DO NOT share this course assignment with any person/entity. Please be reminded that you have ‘agreed’ to the BHIS Code of Conduct at the beginning of the course which outlines the Academic Integrity policy of the university (i.e. altering or transmitting without authorization, academic information or records).
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