Create a physician query for a DRG denial based on the case study. Determine a process for compliance review.
The purpose for this assignment is to acquire advanced skills in monitoring and managing compliance by designing a compliant physician query and outlining a method for assessing and addressing a compliance pattern.
Your facility received an initial DRG validation denial letter from the Recovery Audit Program (RAC) contractor. The case scenario includes a 75-year-old patient admitted through the Emergency Department for renal failure and COPD exacerbation. The reason for admission is COPD exacerbation. The physician also documented protein-calorie deficiency malnutrition in the discharge summary. The RAC contractor indicates the diagnosis of protein-calorie deficiency malnutrition as questionable and has determined an overpayment has occurred.
As the CDI Specialist, you review the record in question and notice that the physician’s supporting documentation for the protein-calorie deficiency malnutrition is missing, including whether this condition was present on admission. Wondering if this is a common issue with physician documentation, you review a sample of additional cases of protein-calorie deficiency malnutrition across all physicians. A pattern of poor documentation was revealed. You then formed a work group to address the pattern to decrease future denials.
To address the above issues, do the following:
1. For the issue identified by the RAC contractor,
1. Locate a scholarly article on protein-calorie deficiency malnutrition (e.g., Google Scholar or other scholarly resources http://scholar.google.com)
2. Create a query to the physician to address the MS DRG for the principal diagnosis of COPD exacerbation with protein-calorie deficiency malnutrition. The article should provide supporting clinical content for your query (remember, queries cannot be leading!).
2. For the issue associated with the pattern uncovered,
a. Outline a method for assessing the compliance problem, e.g., what coding validation practice could be implemented. Connect it to a regulatory requirement or guideline.
b. Prepare a document for the work group addressing your findings and methodology.
3. Submit the assignment. Include your name in the assignment file name as well as in the document header.
See rubric on page 2
Criterion Specifics Met / Not Met
Objective – Physician Query
40% (20 points) • Create a physician query
• Content for the query supported by scholarly article
• Compliant with industry guidelines
Objective – Compliance Review
40% (20 points) • Develop a process for compliance review
• Outline method to assess and address a compliance pattern and connect to a regulatory requirement or guideline
• Produce a document that summarizes the findings and methodology
10% (5 points) Proper formatting of in-text citations as well as references.
10% (5 points) Submission mechanics exhibit college-level writing, assignment is professionally correct, the required length, and submitted on time.