Many times I have to ask Legal Nurse Consultants to review an injured client's medical records and the related bills. I'm fascinated by the complexity of this process. Guest Blogger, Susan van Ginneken, a Legal Nurse Consultant, was kind enough to write the following article to help illustrate what it is that she does when reviewing the billing and legal records.
Medical Billing and Legal Records by Susan van Ginneken, RN
As if attorneys and nurses do not have enough to be aware of in the medical record, now someone tells us that billing codes are being misused to render higher bills than the actual services given would suggest. There was a time that if you knew the main diagnosis being treated (Principal Diagnosis), you basically knew what would be billed. Well, that does not hold true any longer. There are now “relative weights” given to various diagnosis groups, and the groups are determined by the amount of care they may require to treat. There is a book of “Diagnosis Related Groupings” or “DRGs” that outlines these, and the average course to learn how to use these codes is two weeks in length. Why is it so complex? Well, because there are “modifiers” such as “co-morbidities” and “complications” that increase the relative weight (amount of money paid) of a diagnosis group when present. Not just any secondary diagnosis will fulfill this category, so you have to know which diagnoses affect which group. There are new modifiers that apply to Acute Renal Failure, and they are not always coded correctly, particularly on emergency department charts. A notice in my latest DRG newsletter warned us to watch for inaccurate coding on those charts.
How does this affect those of us in the legal field? Well, when you are trying to calculate damages, you cannot always go by the coding and figures offered on the bill. If those are inaccurate, Medicare or the Insurance Company may (and probably will) find the error and make the facility correct it. In fact, there is an entire group of coders and nurses working for companies in 3 areas of the country to review and find billing errors, because Medicare feels there is enough billing error in their favor to more than pay for this work! If we use billing information to help us calculate the amount of care a person required, we may well be accepting faulty material. We will then be using information that is obsolete. Better to have someone knowledgeable about the appropriate coding of a chart go through it, before attaching your final dollar figures. The billing people may also see something that everyone else missed, just by noting a code used (for example, a code for Fractured Leg with ORIF and the modifier for the co-morbidity of diabetes). If the co-morbidity was mentioned only very briefly in the chart, it is possible that it may have been over-looked. However, the presence of diabetes on the healing of that fractured leg could be big. This would make a difference in the total medical and long-term healing prospects for the client. On the other hand, if the modifier was used, yet diabetes is never mentioned in the chart, neither they nor we can use that in our work. Copying diagnoses off the face sheet of a chart is risky business. Mistakes can and do happen often.
Susan van, RN Ginneken
Legal Nurse Consultant
Nurse Life Care Planner
Eagle Eye Record Review
“I do Chart Review and Life Care Plan preparation for the care, assistive devices, and services needed after catastrophic injury or illness, as well as billing and coding consultation.”
Coding – the review of a chart by a specialist trained specifically for the task in order to discern the principal diagnosis on a chart and any modifiers that will affect the final relative weight of an assigned DRG category.
Complication – a condition that arises during the hospital stay that prolongs the length of stay by at least one day in approximately 75 percent of the cases.
Co-Morbidity – pre-existing condition that, because of its presence with a specific diagnosis, causes an increase in length of stay by at least one day in approximately 75 percent of cases.
Diagnosis Related Group (DRG) – one of the 579 (538 valid) classifications of diagnoses in which patients demonstrate similar resource consumption and length-of-stay patterns.
Modifier – a “CC” (complication or co-morbidity) that affects the relative weight of a DRG category.
Relative weight – an assigned weight that is intended to reflect the relative resource consumption associated with each DRG. The higher the relative weight, the greater the payment to the hospital. Relative weights are calculated by CMS and published in the final perspective payment rule.
Definitions obtained from:
Ingenix. (2007). DRG desk reference: The ultimate resource for improving DRG assignment practices.
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