/ POSTPAY REVIEWS / DRG REVIEWS /
Using CAVO for DRG Reviews
Let’s see how CAVO DRG Reviews can help in the following scenario. Patient is a 35-year-old female with a history of prosthetic heart valve who presented to the Emergency Department complaining of rectal bleeding and heavy menstrual period for six days. She was especially concerned because she takes Coumadin to help thin her blood and wanted to ensure she wasn’t bleeding too much. She was subsequently admitted to the hospital for three days with a diagnosis of Lower GI Bleed with a CC of Acute Posthemorrhagic Anemia.
Patient has a 232-page medical record, and the provider has submitted a claim for 378, G. I. Hemorrhage w/CC. Payer claims analyst has been assigned to review before payment.
CASE REVIEW STEPS
DETAILED FOR CAVO
Step 1: Verify DRG code.
Let’s search for the emergency department documentation to verify that this claim is correctly coded. We search emergency department. Result is “Consent to Treat” and Emergency Department check-in documents, which do not verify the DRG since they represent the patient’s perspective versus the physician’s.
Let’s consider unique words we can search that may correspond to the Emergency Department that will help us quickly locate the correct pages within the record. We decide to search triage. Three results appear – with the first result being the same “Consent to Treat” documents. However, the second result is a report titled “T-System RN Note.” We are looking for a doctor’s note versus a nurse’s note, but this result does help us refine our search. Therefore, we now search t-System AND md. The result is the physician’s note, where we find an admission diagnosis on the last page. We are able to verify the GI bleed is correct and was present on admission.
Searching for the admission diagnosis alone will likely generate 100s of results given how often it appears in the medical record.
Step 2: Check industry guidelines and/or patient’s insurance policy.
Based on industry guidelines, we need to check the patient’s hemoglobin and hematocrit levels to verify the CC of Acute Posthemorrhagic Anemia. Let’s search hemoglobin to find the lab result. Seven results are displayed, but we do not see the actual lab result.
Let’s search hgb in case hemoglobin is abbreviated within the lab result. This search renders eight results, and the first is the lab report (which is exactly what we would like to review). So, with two searches in CAVO for this step, we’re now reviewing a 7-page lab report, which is approximately 3% of the original medical record volume.
While the lab report is pulled up, is there any other information we need from this document? Hematocrit levels are listed directly below the hemoglobin level, so no additional search is required.
It’s often helpful to search:
abbreviations for labs.
generic names for medications.
RESULTS WITH CAVO
Previous DRG Reviews Process
Search: Manually index medical record; create a worksheet template; and read each progress note, consult, etc. to make a decision determination.
Time Investment: 130 minutes
CAVO DRG Review Process
Search: Five online searches, as outlined above. Note: different search logic can also produce the same determination but with varying numbers of searches and time investments.
Time Investment: 20 minutes
Payer claims analyst did not find adequate documentation of acute severe anemia. Therefore, claim will be downgraded. Specifically, DRG 378, G. I. Hemorrhage w/CC will be downgraded to 379, G. I. Hemorrhage w/o CC/MCC.