Physician review improves hospital DRG reimbursement in injury

Abstract

This was a prospective study of all DRG reimbursed trauma patients discharged during an 11-month period. Initial DRGs were assigned by hospital coding specialists (HCS). A surgeon (SURG) subsequently reviewed each chart and assigned DRGs to maximize reimbursement. The data for 244 patients were: age = 36.5 years, Trauma Score (TS) = 13.8, Injury Severity Score (ISS) = 16.9, and length of stay (LOS) = 10.3 days. Total charges for the 244 patients were $4,261,208 with an initial HCS projected reimbursement of $1,687,963. The SURG review resulted in a total projected reimbursement of $1,956,476, an increase of $268,513 in revenue (p less than 0.001). Charges correlated strongly with LOS and ISS. The HCS-coded and SURG-coded reimbursements also correlated positively with LOS and ISS, but to a lesser extent. The SURG review of DRG assignment improved hospital reimbursement for the injured patients. However, this reimbursement fell well below hospital billings.