title: 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.
authors.affiliation: Trauma Service, Grant Medical Center, Ohio State University, Columbus 43215.
authors.forename: R E
authors.initials: RE
authors.lastname: Falcone
authors.forename: S R
authors.initials: SR
authors.lastname: Wanamaker
authors.forename: J
authors.initials: J
authors.lastname: Monk
authors.forename: L C
authors.initials: LC
authors.lastname: Carey
authors.forename: C
authors.initials: C
authors.lastname: Valenziano
mesh_terms: D000043:Abstracting and Indexing / Q000592:standards*; D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D006259:Craniocerebral Trauma / Q000175:diagnosis / Q000191:economics; D003953:Diagnosis-Related Groups; D005249:Fees and Charges / Q000706:statistics & numerical data; D005260:Female; D013502:General Surgery; D006784:Hospitals, Teaching; D006786:Hospitals, Urban; D006801:Humans; D015601:Injury Severity Score; D007348:Insurance, Health / Q000145:classification / Q000706:statistics & numerical data; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000175:diagnosis* / Q000191:economics / Q000401:mortality; D009820:Ohio / Q000453:epidemiology; D010820:Physicians / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012051:Reimbursement Mechanisms / Q000592:standards* / Q000706:statistics & numerical data; D015599:Trauma Severity Indices; D014600:Utilization Review / Q000379:methods / Q000592:standards*