Reliability of Medicare Hospital Discharge Records Report of a Study (1977) / Chapter Skim
Currently Skimming:
Analysis
Analysis
Pages 23-60
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 23... ...
Occasionally, the data provided by HCFA and the IOM field team were equally acceptable. This was particularly true for diagnostic data, where 4.6 percent of all sets of abstracts had a different principal diagnosis on each data source and "either" diagnosis was an acceptable choice.
|
From page 24... ...
Presence of 74.5 1.3 23.5 0.7 - 100.0 additional dlagnosls Principal 78.9 1.7 17.3 1.7 0.4 100.0 Procedure Unweighted N = 4745 The analysis was guided by several factors considered in the previous study and thought to influence reliability, including: · the potential inadequacies of current nomenclature, coding guidelines, and medical recording practices for definitively determining and coding a principal diagnosis or principal procedure and the resultant need of abstracters to exercise some judgment which may lessen reliability; · the degree of coding refinement (four-digit, three-digit, or broader diagnostic classifications such as AUTOGRP) ; · the contribution of individual diagnoses to the overall discrepancy rates; · the contribution of the actual coding and processing of claims information by HCFA personnel; and
|
From page 25... ...
ANALYSIS OF DIAGNOSTIC INFORMATION In analyzing diagnostic information, the reasons explaining discrepancies between the diagnoses coded by HCFA and the field team were first explored in hopes of eliciting general clues about potential reasons for differences. The concordance between admitting and principal diagnosis was examined next to determine whether hospitals may submit admitting diagnoses, rather than principal, to facilitate reimbursement for the Medicare claims.
|
From page 26... ...
Correct data source Reason for Medicare IOM discrepancy Record* Abstract Either Neither*
|
From page 27... ...
Anecdotal data transmitted informally by medical record and billing department supervisors to the field team indicate a considerable amount of variation among hospitals with respect to the definition of principal diagnosis.
|
From page 28... ...
The actual coding of a diagnosis was more of a problem when discrepancies were analyzed at the fourth digit, than if only the first three-digits were compared or if AUTOGRP was used. For coding discrepancies where the IOM abstract was correct, the reason usually given by the field team was "coding-completeness," suggesting that a narrative was selected to describe the principal diagnosis without completely reviewing the medical record.
|
From page 29... ...
The "coding other" reason for discrepancy also was used with relatively equal frequency regardless of the level of coding refinement. In 50.7 percent of these 207 cases, the diagnostic code listed by BCFA was 799.9, which indicates that the claim form did not contain acceptable diagnostic information, although the field team had coded a principal diagnosis.
|
From page 30... ...
To explore this possibility, the field team determined an admitting diagnosis for each case, based only on information contained in the face sheet of the medical record, history and physical reports, and admitting or emergency room notes. This was compared with the principal diagnosis, based on a careful examination of the entire record.
|
From page 31... ...
The categories with less accurate data include chronic ischemic heart disease, cerebrovascular diseases, diabetes mellitus, intestinal obstruction without mention of hernia, and congestive heart failure. The percent of cases where "either" data source was correct is highest for chronic ischemic heart disease, diabetes mellitus, and bronchopneumonia and unspecified pneumonia.
|
From page 32... ...
Level of Correct data source where .
|
From page 33... ...
. c Diagnoses on Medicare record Chronic ischemic heart disease Cerebrovascular diseases Fracture, neck of femur Cataract Acute myocardial infarction 9.8 6.9 2.0 3.0 2.4 36.8 4.0 58.5 3.5 70.5 3.0 97.3 0.2 67.3 50.3 7.6 1.3 100.0Z 33.8 4.2 - 100.0 26.5 2.5 1.0 28.8 2.9 100.0 100.0 100.0 Inguinal hernia without mention of obstruction 1.
|
From page 34... ...
Principal AUTOGRP diagnosis: AUTOGRP digit digit diagnosis: classi- Specific classi- compar- compar Entire DRG fication sub-category fication ison ison Ischemic heart disease except AMI 40.1 Cerebrovascular diseases 84.7 Fractures 87 .7 Diseases of the eye 95.0 Acute myocardial infarction 76.1 Hernia of abdominal cavity 89.8 Diabetes mellitus 56.2 Chronic ischemic heart disease Cerebrovascular diseases Fracture, neck of femur Cataract 97.9 Acute myocardial infarction 76.1 Inguinal hernia without mention of obstruction Diabetes mellitus 38.6 38.6 36.% 84 .
|
From page 35... ...
Hyperplasia of the prostate Bronchopneumoniaorganism not specified 87.1 87.1 87.1 and pneumonia organism and type not specified 80.5 75.9 75.9 Cholelithiasis/ cholecystitis Intestinal obstruction without mention of hernia Congestive heart failure and left ventricular failure 84.4 76.3 62.8 68.8 68.8 58.1 60.6 61.0 58.5 Diverticulosis of intestine 86.9 86.9 86.5 Bronchitis Malignant neoplasm of bronchus and lung All else 95.7 89.8 89.8 79.9 79.9 79.9 *
|
From page 36... ...
For most diagnoses that had a relatively low level of reliability in Table 8, the percent of abstracts with no discrepancy increased if the analysis was confined to those with no additional diagnoses. This was particularly evident for chronic ischemic heart disease, acute myocardial infarction, diabetes, congestive heart failure, and intestinal obstruction without mention of hernia.
|
From page 37... ...
~ _,_ Correct data source . I Principal IOM abstract Either ~ ~ .' .
|
From page 38... ...
7 Acute myocardial infarction 185 63.1 42 84.9 Inguinal hernia without mention of obstruction 79 94.1 61 99 .7 Diabetes mellitus 211 47 .2 13 90.6 Hyperplasia of the prostate 157 84.0 72 95 .9 Bronc ho pneumoni a-o rg ant sm not specified and pneumonia organism and type not specified 177 74.6 32 81 .0 Cholelithiasis/cholecystitis 139 62.3 45 64. 5 Intestinal obstruction without mention of hernia 70 SO .6 27 86 .6 Congestive heart failure and left ventricular failure 137 53 .
|
From page 39... ...
There does not appear to be a systematic bias within the hospitals to submit an admitting diagnosis on the claim form in lieu of a more carefully established principal diagnosis.
|
From page 40... ...
Ordering problems occurred less frequently than coding errors. When they were noted and the IOM abstract was correct, the specific reason most frequently selected was "ordering-completeness." Thus, an incomplete review of the medical record accounted for about forty percent of all discrepancies when the IOM abstract was correct.
|
From page 41... ...
. Correct data source Reason for d~E25——y Ordering-SSA definition Record Abstract Either Neither*
|
From page 42... ...
In addition, some discrepancies may occur because Medicare personnel attempt to code everything that appears in the principal procedure position on the claim form. In some cases the field team may have felt that a particular procedure should be listed as principal in accord with UHDDS and wrote the procedure on the abstract form.
|
From page 43... ...
The reasons for discrepancy usually stemmed from coding problems, rather than ordering, and the most frequent reason was the failure to adequately review the medical record before recording a narrative on which the code for principal procedure was based. ANALYSIS OF CLAIMS INFORMATION As noted earlier, the analyses completed to this point are based on comparisons between the Medicare record and the IOM abstract, assuming that data on the Medicare record accurately reflect information from the claim form submitted by the hospital to the fiscal intermediary and, eventually, to HCFA.
|
From page 44... ...
Therefore, information from all cases with discrepancies on principal diagnosis between the Medicare record and IOM abstract (where the field team had obtained a copy of the appropriate claim form) was submitted to senior HCFA RRAs to determine the accuracy of the HCFA coding function.
|
From page 45... ...
IOM abstract = claim first-listed (claim reflects patient condition) n = 344 First-listed Special convention Totals IOM abstract ~ claim first-listed (claim does not reflect patient condition)
|
From page 46... ...
Table 17. Reliability of Medicare Coding of Three-Digit Principal Diagnosis for Cases Where There Were Discrepancies Between Medicare Record and IOM Abstract Percent of cases in which Medicare code agrees with first-listed diagnosis on claim form Re-coding for IOM study DisAgree agree Total Accuracy status Initial coding Dls and coding method Agree agree Total IOM abstract = claim first-listed (claim reflects patient condition)
|
From page 47... ...
For the remaining twenty-four percent, the Medicare record did not agree with the claim form data, presumably because of the appropriate application of a special HCFA coding guideline or because of a mistake. As with diagnoses, the data gathered by the field team did not permit a direct assessment of the frequency with which discrepancies might stem from either the correct application of a Medicare coding guideline or
|
From page 48... ...
To ascertain this, information from all cases with discrepancies on principal procedure between the Medicare record and the IOM abstract (where the field team had obtained a copy of the appropriate claim forms) was submitted to senior HCFA RRAs to determine the reliability of the HCFA coding function.
|
From page 49... ...
~ . IOM abstract = claim first-listed ~ claim re f lec t s pat tent care n = 205 First-listed 67.0 33.0 100.0 (80.8)
|
From page 50... ...
Calculation of Net and Gross Difference Rates in Designation of Principal Diagnosis IOM abstracts coded as principal Medicare record coded as principal Specific diagnosis Other Total Specific . ~ C .lagllOS IS Other a b a + b c d c ~ d ..
|
From page 51... ...
The IOM admission rates are calculated by dividing the total number of IOM abstracts with a specific diagnosis (including false negatives)
|
From page 52... ...
However, the IOM admission rates, which include the false negatives, are higher than the Medicare rates with the exception of chronic ischemic heart disease, diabetes, and malignant neoplasm of bronchus and lung. The under-estimation of admissions using Medicare data is particularly noticeable for cerebrovascular disease and congestive heart failure.
|
From page 53... ...
7 12. 7 13.8 Diabetes mellitus 12.6 14.2 23.7 25.4 21.1 Hyperplasia of the prostate 18.6 18.6 21.3 21.3 22.4 Broncho pneumonia organism not specified and pneumonia-organism and type not specified Cholel ithiasis/ cholecystitis 12.1 Intestinal obstruction without mention of hernia 5 .4 Congestive heart failure and le ft ventr icular failure Diverticulosis of the inte st ine Bronchi tis Mal ignant neoplasm of bronchus and and lung 9 .2 9 .2 11 .
|
From page 54... ...
Ischemic heart disease .
|
From page 55... ...
1 12.5 13.4 Intestinal obstruction without mention of hernia 12.2 12.7 13.8 14.0 11.3 Congestive heart failure and left ventricular failure 9.4 9.2 10.0 9.8 11.3 Diverticulosis of intestine 8.3 8.3 9.0 9.0 10.6 Bronchitis 7.9 7.9 8.3 8.3 8.2 Malignant neoplasm of bronchus and lung _
|
From page 56... ...
0 Heart failure 10.1 10.4 11.7 Enteritis, diverticula and functional dis orders of intestine 8.1 8.7 10.2 Bronchitis 7.9 8.2 8.2 Mal ignant neoplasm of respiratory system 13.0 11.8 13.
|
From page 57... ...
Relationships Between Hospital and Abstracting Process Characteristics and the Accuracy of Information on Diagnosis and Procedure Four-digit Characteristics diagnosis diagnosis Procedures ~ , . Personnel and Training Training of billing Billing office Same as four- Not appro personnel where they training with no digit priate for review portions of medical record procedure records for experience = diagnosis better data Training of personnel abstracting informawhere billing uses abstracted data Data from Same as four- Same as four physicians and digit digit RRAs are better than ARTs or others 3 Because of the instability of the weighted numbers, the chi-square was based on a re-distribution of the unweighted numbers according to the weighted percentages.
|
From page 58... ...
. Four-digit Three-digit Characteristics diagnosis diagnosis Procedures Abstracting Process Source of abstracted Typed discharge Same as four- Copy of face data used by billing list or copy digit except sheet or en of face sheet = admit sheet tire record = more accurate; or entire more accurate computerized record = data; typed discharge list = least accurate discharge least accurate list = least Description of diag- Diagnostic codes Same as four- Not appro nostic data received more accurate digit diag- priate for by billing than narrative nosis procedure description Time lapse between Significant Significant Not appro patient discharge but not but not priate for and transfer of meaningful meaningful procedure diagnostic infor mation to billing Time lapse between patient discharge and determination of a final diag nosls Significant Significant Not appro but not but not priate for meaningful meaningful procedure Submission of up- Submission of Not signifi- Not appro dated diagnostic updated infor- cant priate for information to mation = more procedure billing office accurate data Submission of up- Submission of Same as three- Not approp cated diagnostic updated infor- digit priate for information to mation = more procedure the fiscal inter- accurate data mediar, Definitions used in Use of Medicare Same as three- Not signif determing princi- definition = more digit icant pal diagnosis or accurate; first procedure listed = less accurate
|
From page 59... ...
Similarly, the data were more accurate in hospitals where up-dated diagnostic information is regularly submitted to the billing department, as well as to the fiscal intermediary. The various definitions for principal diagnosis and principal procedure used by the study hospitals were expected to influence the reliability of data.
|
From page 60... ...
Despite these limitations, it appears that billing office personnel with training in billing procedures, but no medical record experience, may provide accurate diagnostic information if accurate information is provided by the medical record department. If RRAs abstract and code the information and submit it to the billing office, the data forwarded to the fiscal intermediaries tend to be more accurate.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.