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Quality and creativity in coding. 4th Nordic Casemix Conference Helsinki, 3 June 2010 Jens Lind Knudsen Ministry of Interior and Health, Denmark. The quality of DRG depends on many factors. Good coding Good code classifications Good cost data Good systems for collecting the data

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quality and creativity in coding

Quality and creativity in coding

4th Nordic Casemix Conference

Helsinki, 3 June 2010

Jens Lind Knudsen

Ministry of Interior and Health, Denmark

the quality of drg depends on many factors
The quality of DRG depends on many factors
  • Good coding
  • Good code classifications
  • Good cost data
  • Good systems for collecting the data
  • Good DRG classifications
  • Good studies on the data
  • Good systems to disseminate the results
  • Good ways to follow up on the results
  • Dedicated staffs to develop and maintain all this!

4th Nordic Casemix Conference, Helsinki 2010

quality of the systems around coding
Quality of the systems around coding
  • You should be able to code what you do!
  • It should be easy to find the codes!
  • Cooperate with the medical associations!
  • The DRG classification must not provide incentives to poor coding!
  • Clear and transparent DRG classification!
  • Ongoing evaluation of the quality of coding!

4th Nordic Casemix Conference, Helsinki 2010

1 you should be able to code what you do
1. You should be able to code what you do!

The Nordic DRG classifications are based on diagnoses (IDC10) and procedures:

Surgical procedures(Nordic Classification of Surgical Procedures)

Treatment procedures(National classifications)

Examination procedures(National classifications)

etc.

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4th Nordic Casemix Conference, Helsinki 2010

1 you should be able to code what you do1
1. You should be able to code what you do!

Classifications must be kept up to date constantly!

It must be possible to open new codes- quickly and easily!

It must be possible to place new codes in the DRG classification as the codes are opened!

The Danish code classifications are updated four times a year – with a corresponding update of the DRG classification!

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4th Nordic Casemix Conference, Helsinki 2010

2 it must be easy to find the codes
2. It must be easy to find the codes!

Simple access tocode classifications!

Easy-to-use coding guidelinesthat fit in the coat pocket!

It must be easy to code well!

Central authorities setsthe principles!

Let the medical societiesdevelop the guidelines!

4th Nordic Casemix Conference, Helsinki 2010

3 cooperating with the medical societies
3. Cooperating with the medical societies

When constructing DRGs we should emphasize

The groups must be meaningful clinically

The groups must be homogeneous as to resources

Not TO many groups…

When choosing between two good solutions to a classification problem in DkDRG, we often choose the more meaningful clinically.

4th Nordic Casemix Conference, Helsinki 2010

3 cooperating with the medical societies1
3. Cooperating with the medical societies

The Ministry collaborates closely with all medical associations when developing and maintaining the DRG classification.

The Danish hospitals are providing the data for the calculation of the cost weights.

Result:

The hospitals and the doctors areaccepting the measure!

They have made the measure themselves!

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4th Nordic Casemix Conference, Helsinki 2010

3 cooperating with the medical societies2
3. Cooperating with the medical societies

Complicated reconstruction, knee

Other surgical procedures, back

% of discharges/visits

% of discharges/visits

Cost per discharge/visit

Length of stay

4th Nordic Casemix Conference, Helsinki 2010

3 cooperating with the medical societies3
3. Cooperating with the medical societies

Complicated reconstruction, knee

Other surgical procedures, back

% of discharges/visits

% of discharges/visits

Cost per discharge/visit

Length of stay

ongoing process

4th Nordic Casemix Conference, Helsinki 2010

4 no incentives to bad coding in drg classifications
4. No incentives to bad coding in DRG classifications!

In Denmark secondary diagnoses should be coded if they are “clinical relevant”.

Whether a diagnosis is clinical relevant or not is up to the physician to decide.

Some doctors will see a diagnosis as relevant – others will see it as not relevant.

Whether a secondary diagnosis is coded or not can be random.

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4th Nordic Casemix Conference, Helsinki 2010

4 no incentives to bad coding in drg classifications1
4. No incentives to bad coding in DRG classifications!

If the hospital is funded with a DRG system where secondary diagnoses might result in higher rates – there is an incentive to code diagnoses with a small indication.

Denmark chose to base complication splits mainly on procedures.

Splits on procedures can outline hospitals with highly specialised procedures.

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4th Nordic Casemix Conference, Helsinki 2010

5 a transparent classification
5. A transparent classification

In Denmark the DkDRG system moves around 145 billion DKK (20 billion Euros).

An instrument that moves so much money must be transparent.

If we want the patients classified correctly in the DRGs, we must make it easy for the doctors to choose the necessary and sufficient diagnoses for a correct grouping.

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4th Nordic Casemix Conference, Helsinki 2010

slide14

5. A transparent classification

4th Nordic Casemix Conference, Helsinki 2010

slide15

5. A transparent classification

4th Nordic Casemix Conference, Helsinki 2010

slide16

5. A transparent classification(?)

4th Nordic Casemix Conference, Helsinki 2010

slide17

5. A transparent classification

4th Nordic Casemix Conference, Helsinki 2010

slide18

5. A transparent classification

4th Nordic Casemix Conference, Helsinki 2010

slide19

5. A transparent classification

4th Nordic Casemix Conference, Helsinki 2010

slide20

5. A transparent classification(?)

4th Nordic Casemix Conference, Helsinki 2010

5 a transparent classification1
5. A transparent classification

Non-transparency in the classification can lead to inefficient coding practices.

In Denmark we are working on removing the build-in complication feature from DkDRG from 2012.

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4th Nordic Casemix Conference, Helsinki 2010

6 ongoing evaluation of the coding
6. Ongoing evaluation of the coding
  • confidence is good
  • control is better

4th Nordic Casemix Conference, Helsinki 2010

6 ongoing evaluation of the coding1
6. Ongoing evaluation of the coding
  • confidence is good
  • control may be better
  • cooperation is even better
  • partnership may be best

4th Nordic Casemix Conference, Helsinki 2010

6 ongoing evaluation of the coding2
6. Ongoing evaluation of the coding

Four main scenarios of bad coding:

Under-coding (to few codes)

Over-coding (to many correct, but unnecessary codes)

Up-coding (fraud, with an effect on DRG rates)

Errors (ends up in DRGs for errors)

The evaluation should continuously follow at least these four scenarios.

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4th Nordic Casemix Conference, Helsinki 2010

new born babies
New born babies

4th Nordic Casemix Conference, Helsinki 2010

Discharges 2009, DkDRG 2010

new born babies healthy or not
New born babies – healthy or not?

4th Nordic Casemix Conference, Helsinki 2010

Discharges 2009, DkDRG 2010

new born babies healthy or not1
New born babies – healthy or not?

4th Nordic Casemix Conference, Helsinki 2010

Discharges 2009, DkDRG 2010

new born babies healthy or not2
New born babies – healthy or not?

4th Nordic Casemix Conference, Helsinki 2010

Discharges 2009, DkDRG 2010

new born babies healthy or not3
New born babies – healthy or not?

4th Nordic Casemix Conference, Helsinki 2010

Discharges 2009, DkDRG 2010

new born babies healthy or not4
New born babies – healthy or not?

4th Nordic Casemix Conference, Helsinki 2010

Discharges 2009, DkDRG 2010

new born babies healthy or not5
New born babies – healthy or not?

4th Nordic Casemix Conference, Helsinki 2010

Discharges 2009, DkDRG 2010

discharges mdc 14 no of diagnoses
Discharges MDC 14 – no. of diagnoses

Discharges 2009, DkDRG 2010

4th Nordic Casemix Conference, Helsinki 2010

discharges mdc 14 no of diagnoses1
Discharges MDC 14 – no. of diagnoses

Total no ofdiagnoses

35.996

5,4 => 22.232

3,3 => 15.744

Discharges 2009, DkDRG 2010

4th Nordic Casemix Conference, Helsinki 2010

quality and creativity in coding1
Quality and creativity in coding
  • You should be able to code what you do!
  • It should be easy to find the codes!
  • Cooperate with the medical associations!
  • The DRG classification must not provide incentives to poor coding!
  • Clear and transparent DRG classification!
  • Ongoing evaluation of the quality of coding!

4th Nordic Casemix Conference, Helsinki 2010

thank you
Thank you

Thank you!

Jens Lind Knudsenjlk@im.dk

14 November 2009

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4th Nordic Casemix Conference, Helsinki 2010