Reliability of Medicare Hospital Discharge Records Report of a Study (1977) / Chapter Skim
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Study Methods
Study Methods
Pages 5-22
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From page 5... ...
(The Medicare information had been compiled by HCFA frog claim forms submitted by the study hospitals to the fiscal intermediary for payment.) Discrepancies between the Institute of Medicine (IOM)
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From page 6... ...
The basic hospital weights were adjusted to reflect the reduced sample size. Sample of Medicare Records The sample design for selecting records to be independently abstracted was guided by several considerations.
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As an example, cataract is a specific diagnosis from the DRG o f "Di seases of the Eye'' and was sampled with a higher frequency than the residual sub-group within that DRG. In some cases, the DRG contained only the specific diagnosis - for example, diabetes or cerebrovascular diseases - and there was no residual sub-group.
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From page 8... ...
In some instances, however, the medical record was not available in the medical record department, and no substitutions were made. As a result, 4,745 medical records were actually independently abstracted by the IOM field team.
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Fractures Specific diagnosis Residual diagnosis none Fracture, neck 820.0-820.9 of femur*
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Hernia of abdominal cavity Specific diagnosis Residual diagnosis Inguinal hernia 550 without ment ion of ob struct ion^ Inguinal hernia 552 with ob struct ion ~ satellite) Other hernia of abdominal cavi ty without mention of ob struct ion Other hernia of abdominal cavi ty wi th ment ion o f ob s true t ion 551 .0-551 .9 553 .
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Diseases of the gall bladder and bile duct Specific diagnosis Residual diagnosis 11. Miscellaneous diseases of the intestine and peritoneum Specific diagnosis Diabetes*
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Enteritis, diverticula, and functional disorders of intestine Specific diagnosis Residual diagnosis 14. Bronchitis Specific diagnosis Residual diagnosis Peritonitis, peritoneal adhesions, and other diseases of intestine and peritoneum Congestive heart failure and left ventricular failure Acute heart failure, undefined Diverticulosis of intestine Noninfectious 5 61 gastroenteritis and colitis, except ulcerative Chronic enteritis and ulcerative colitis Functional disorders of intestine Bronchitis none 567 .0-567 .9; 568; 569 .
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From page 13... ...
Retrieval of Medicare Claim Forms As noted earlier, the field team was instructed to consult the hospital's copy of the Medicare claim form when a discrepancy was found between the IOM abstract and the Medicare record that was not attributable to the field work. (Mistakes by the field team were expected to result in a determination that the Medicare record was correct, so there would be no need to consult the claim form.)
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From page 14... ...
013-75 (9/75~. Although the title specifically refers to surgical procedures, the contents include procedures which are not surgical -- for example, transfusion -- and which also appear on the Medicare claim form.
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From page 15... ...
This information was used to explore the possibility that the primary diagnosis, contained in the Medicare record, may be in reality an admitting diagnosis, rather than a more definitive principal diagnosis, because of the urgency to submit a claim form for reimbursement. The presence of additional diagnoses was also noted -- again, in accord with specific guidelines.
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From page 16... ...
The following specific types of ordering discrepancies were considered: Ordering: Medicare definition - discrepancies reflecting differences between the UHDDS definition and that required for the Medicare claim form, which should occur only if a hospital consciously and consistently used the Medicare definition in completing the claim forms in 1974. For example, a patient is admitted for an open fracture reduction and while on the operating table suffers an acute myocardial infarction which requires a three-month hospitalization.
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From page 17... ...
The field team was instructed to write a note explaining the necessity to use this reason. Ordering: Dependent - this option applied only to discrepancies on principal procedure and was used if an earlier discrepancy in the selection of principal diagnosis resulted in a corresponding or dependent discrepancy in the selection of principal procedure.
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From page 18... ...
This option was expected to be used to explain differences when the field team coded a procedure, but Medicare coders did not because the information on the claim forms was illegible or inappropriate. A note of explanation was required if this option was selected.
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The first-listed diagnosis and related procedure was then coded by the field team since this procedure is usually followed by Medicare coders. To expedite the field work, comparisons between the claims data and the Medicare record were performed by computer at the National Academy of Sciences (NAS)
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From page 20... ...
During initial meetings with local hospitals and Medicare officials to determine the feasibility of conducting this study, it became apparent that the paths by which claims information eventually enters the HCFA computer vary considerably. In some hospitals, when a patient is discharged the medical record department sends the billing office a discharge list, including information on diagnoses and procedures needed to complete the claim form.
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From page 21... ...
When the field team member arrived, she first informally discussed the checklist items with the supervisor to acquaint herself with any unusual hospital procedures that might influence the abstracts, and immediately began abstracting. ~ The completed abstracts were compared with the Medicare records (contained in a sealed envelope to avoid conditioning the abstracting)
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From page 22... ...
CONFIDENTIALITY To retrieve the medical records and claim forms within study hospitals, it was necessary for HCFA to provide the IOM with the health insurance claim number, name and birth date of the beneficiary, and date of hospital admission and discharge for each hospital episode reviewed. To review the accuracy of diagnostic and procedural coding, a partial review of the medical record was required.
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