Importance of coding co-morbidities for APR-DRG assignment: Focus on cardiovascular and respiratory diseases. Issue 1 (January 2020)

• Record Type: Journal Article
• Authors: Souza, Julio; Santos, João Vasco; Canedo, Veronica Bolon; Betanzos, Amparo; Alves, Domingos; Freitas, Alberto
• Other Names: Shepheard Jennie guest-editor.
• Is Part Of: Health information management journal. Volume 49:Issue 1(2020)
• Page Start: 47
• Page End: 57
• Publication Date: 2020-01
• Subjects: hospitals -- Diagnosis-Related Groups -- clinical coding -- medical informatics; support vector machine -- data accuracy -- hospital administration -- machine learning; Medical records -- Management -- Periodicals; Medical records -- Management -- Australia -- Periodicals; Medical records -- Management; Australia; Periodicals; Periodicals; 651.50426105
• DOI: 10.1177/1833358319840575
• Languages: English
• ISSNs: 1833-3583

Abstract

Background: The All Patient-Refined Diagnosis-Related Groups (APR-DRGs) system has adjusted the basic DRG structure by incorporating four severity of illness (SOI) levels, which are used for determining hospital payment. A comprehensive report of all relevant diagnoses, namely the patient's underlying co-morbidities, is a key factor for ensuring that SOI determination will be adequate. Objective: In this study, we aimed to characterise the individual impact of co-morbidities on APR-DRG classification and hospital funding in the context of respiratory and cardiovascular diseases. Methods: Using 6 years of coded clinical data from a nationwide Portuguese inpatient database and support vector machine (SVM) models, we simulated and explored the APR-DRG classification to understand its response to individual removal of Charlson and Elixhauser co-morbidities. We also estimated the amount of hospital payments that could have been lost when co-morbidities are under-reported. Results: In our scenario, most Charlson and Elixhauser co-morbidities did considerably influence SOI determination but had little impact on base APR-DRG assignment. The degree of influence of each co-morbidity on SOI was, however, quite specific to the base APR-DRG. Under-coding of all studied co-morbidities led to losses in hospital payments. Furthermore, our results based on the SVM models were consistent with overall APR-DRG grouping logics. Conclusion and implications: Comprehensive reporting of pre-existing or newly acquired co-morbidities should be encouraged in hospitals as they have an important influence on SOI assignment and thus on hospital funding. Furthermore, we recommend that future guidelines to be used by medical coders should include specific rules concerning coding of co-morbidities.