Quality and creativity in coding 4th Nordic Casemix Conference Helsinki, 3 June 2010 Jens Lind Knudsen Ministry of Interior and Health, Denmark

4th Nordic Casemix Conference, Helsinki 2010 The quality of DRG depends on many factors  Good coding  Good code classifications  Good cost data  Good systems for collecting the data  Good DRG classifications  Good studies on the data  Good systems to disseminate the results  Good ways to follow up on the results  Dedicated staffs to develop and maintain all this!

4th Nordic Casemix Conference, Helsinki 2010 Quality of the systems around coding 1. You should be able to code what you do! 2. It should be easy to find the codes! 3. Cooperate with the medical associations! 4. The DRG classification must not provide incentives to poor coding! 5. Clear and transparent DRG classification! 6. Ongoing evaluation of the quality of coding!

4th Nordic Casemix Conference, Helsinki You should be able to code what you do!  The Nordic DRG classifications are based on diagnoses (IDC10) and procedures:  Surgical procedures (Nordic Classification of Surgical Procedures)  Treatment procedures (National classifications)  Examination procedures (National classifications)  etc.

4th Nordic Casemix Conference, Helsinki November You should be able to code what you do!  Classifications must be kept up to date constantly!  It must be possible to open new codes - quickly and easily!  It must be possible to place new codes in the DRG classification as the codes are opened!  The Danish code classifications are updated four times a year – with a corresponding update of the DRG classification!

4th Nordic Casemix Conference, Helsinki It must be easy to find the codes!  Simple access to code classifications!  Easy-to-use coding guidelines that fit in the coat pocket!  It must be easy to code well!  Central authorities sets the principles!  Let the medical societies develop the guidelines!

4th Nordic Casemix Conference, Helsinki Cooperating with the medical societies  When constructing DRGs we should emphasize 1. The groups must be meaningful clinically 2. The groups must be homogeneous as to resources 3. Not TO many groups…  When choosing between two good solutions to a classification problem in DkDRG, we often choose the more meaningful clinically.

4th Nordic Casemix Conference, Helsinki Cooperating with the medical societies  The Ministry collaborates closely with all medical associations when developing and maintaining the DRG classification.  The Danish hospitals are providing the data for the calculation of the cost weights.  Result:  The hospitals and the doctors are accepting the measure!  They have made the measure themselves!

4th Nordic Casemix Conference, Helsinki Cooperating with the medical societies Cost per discharge/visitLength of stay % of discharges/visits Complicated reconstruction, knee Other surgical procedures, back

4th Nordic Casemix Conference, Helsinki 2010 Cost per discharge/visitLength of stay % of discharges/visits Complicated reconstruction, knee Other surgical procedures, back 3. Cooperating with the medical societies ongoing process

4th Nordic Casemix Conference, Helsinki November No incentives to bad coding in DRG classifications!  In Denmark secondary diagnoses should be coded if they are “clinical relevant”.  Whether a diagnosis is clinical relevant or not is up to the physician to decide.  Some doctors will see a diagnosis as relevant – others will see it as not relevant.  Whether a secondary diagnosis is coded or not can be random.

4th Nordic Casemix Conference, Helsinki November No incentives to bad coding in DRG classifications!  If the hospital is funded with a DRG system where secondary diagnoses might result in higher rates – there is an incentive to code diagnoses with a small indication.  Denmark chose to base complication splits mainly on procedures.  Splits on procedures can outline hospitals with highly specialised procedures.

4th Nordic Casemix Conference, Helsinki November A transparent classification  In Denmark the DkDRG system moves around 145 billion DKK (20 billion Euros).  An instrument that moves so much money must be transparent.  If we want the patients classified correctly in the DRGs, we must make it easy for the doctors to choose the necessary and sufficient diagnoses for a correct grouping.

4th Nordic Casemix Conference, Helsinki A transparent classification

4th Nordic Casemix Conference, Helsinki A transparent classification

4th Nordic Casemix Conference, Helsinki A transparent classification(?)

4th Nordic Casemix Conference, Helsinki A transparent classification

4th Nordic Casemix Conference, Helsinki A transparent classification

4th Nordic Casemix Conference, Helsinki A transparent classification

4th Nordic Casemix Conference, Helsinki A transparent classification(?)

4th Nordic Casemix Conference, Helsinki November A transparent classification  Non-transparency in the classification can lead to inefficient coding practices.  In Denmark we are working on removing the build-in complication feature from DkDRG from 2012.

4th Nordic Casemix Conference, Helsinki Ongoing evaluation of the coding  confidence is good  control is better

4th Nordic Casemix Conference, Helsinki Ongoing evaluation of the coding  confidence is good  control may be better  cooperation is even better  partnership may be best

4th Nordic Casemix Conference, Helsinki November Ongoing evaluation of the coding  Four main scenarios of bad coding: 1. Under-coding (to few codes) 2. Over-coding (to many correct, but unnecessary codes) 3. Up-coding (fraud, with an effect on DRG rates) 4. Errors (ends up in DRGs for errors)  The evaluation should continuously follow at least these four scenarios.

4th Nordic Casemix Conference, Helsinki 2010 New born babies Discharges, new born 2009% Hospital health probl minor problhealthytotal health probl minor problhealthy tot Rigshospitalet, Copenhagen ,83,370,9100 University Hospital, province ,14,757,2100 University Hospital, province ,93,078,1100 Major hospital, Copenhagen ,58,176,4100 Major hospital, Copenhagen ,40,074,6100 Minor hospital, Copenhagen ,27,968,9100 Major hospital, province ,414,858,8100 Minor hospital, province ,314,068,7100 Minor hospital, province ,115,261,7100 other major / minor hospitals ,26,770,1100 Total ,46,769,9 100 Discharges 2009, DkDRG 2010

4th Nordic Casemix Conference, Helsinki 2010 New born babies – healthy or not? Discharges, new born 2009% Hospital health probl minor problhealthytotal health probl minor problhealthy tot Rigshospitalet, Copenhagen ,83,370,9100 University Hospital, province ,14,757,2100 University Hospital, province ,93,078,1100 Major hospital, Copenhagen ,58,176,4100 Major hospital, Copenhagen ,40,074,6100 Minor hospital, Copenhagen ,27,968,9100 Major hospital, province ,414,858,8100 Minor hospital, province ,314,068,7100 Minor hospital, province ,115,261,7100 other major / minor hospitals ,26,770,1100 Total ,46,769,9 100 Discharges 2009, DkDRG 2010

4th Nordic Casemix Conference, Helsinki 2010 New born babies – healthy or not? Discharges, new born 2009% Hospital health probl minor problhealthytotal health probl minor problhealthy tot Rigshospitalet, Copenhagen ,83,370,9100 University Hospital, province ,14,757,2100 University Hospital, province ,93,078,1100 Major hospital, Copenhagen ,58,176,4100 Major hospital, Copenhagen ,40,074,6100 Minor hospital, Copenhagen ,27,968,9100 Major hospital, province ,414,858,8100 Minor hospital, province ,314,068,7100 Minor hospital, province ,115,261,7100 other major / minor hospitals ,26,770,1100 Total ,46,769,9 100 Discharges 2009, DkDRG 2010

4th Nordic Casemix Conference, Helsinki 2010 New born babies – healthy or not? Discharges, new born 2009% Hospital health probl minor problhealthytotal health probl minor problhealthy tot Rigshospitalet, Copenhagen ,83,370,9100 University Hospital, province ,14,757,2100 University Hospital, province ,93,078,1100 Major hospital, Copenhagen ,58,176,4100 Major hospital, Copenhagen ,40,074,6100 Minor hospital, Copenhagen ,27,968,9100 Major hospital, province ,414,858,8100 Minor hospital, province ,314,068,7100 Minor hospital, province ,115,261,7100 other major / minor hospitals ,26,770,1100 Total ,46,769,9 100 Discharges 2009, DkDRG 2010

4th Nordic Casemix Conference, Helsinki 2010 New born babies – healthy or not? Discharges, new born 2009% Hospital health probl minor problhealthytotal health probl minor problhealthy tot Rigshospitalet, Copenhagen ,83,370,9100 University Hospital, province ,14,757,2100 University Hospital, province ,93,078,1100 Major hospital, Copenhagen ,58,176,4100 Major hospital, Copenhagen ,40,074,6100 Minor hospital, Copenhagen ,27,968,9100 Major hospital, province ,414,858,8100 Minor hospital, province ,314,068,7100 Minor hospital, province ,115,261,7100 other major / minor hospitals ,26,770,1100 Total ,46,769,9 100 Discharges 2009, DkDRG 2010

4th Nordic Casemix Conference, Helsinki 2010 New born babies – healthy or not? Discharges, new born 2009% Hospital health probl minor problhealthytotal health probl minor problhealthy tot Rigshospitalet, Copenhagen ,83,370,9100 University Hospital, province ,14,757,2100 University Hospital, province ,93,078,1100 Major hospital, Copenhagen ,58,176,4100 Major hospital, Copenhagen ,40,074,6100 Minor hospital, Copenhagen ,27,968,9100 Major hospital, province ,414,858,8100 Minor hospital, province ,314,068,7100 Minor hospital, province ,115,261,7100 other major / minor hospitals ,26,770,1100 Total ,46,769,9 100 Discharges 2009, DkDRG 2010

4th Nordic Casemix Conference, Helsinki 2010 New born babies – healthy or not? Discharges, new born 2009% Hospital health probl minor problhealthytotal health probl minor problhealthy tot Rigshospitalet, Copenhagen ,83,370,9100 University Hospital, province ,14,757,2100 University Hospital, province ,93,078,1100 Major hospital, Copenhagen ,58,176,4100 Major hospital, Copenhagen ,40,074,6100 Minor hospital, Copenhagen ,27,968,9100 Major hospital, province ,414,858,8100 Minor hospital, province ,314,068,7100 Minor hospital, province ,115,261,7100 other major / minor hospitals ,26,770,1100 Total ,46,769,9 100 Discharges 2009, DkDRG 2010

4th Nordic Casemix Conference, Helsinki 2010 Discharges MDC 14 – no. of diagnoses Hospital no of discharges Average no diagnoses Rigshospitalet, Copenhagen4.6944,3 University hospital, province4.1178,7 University hospital, province6.8475,5 Major hospital, Copenhagen5.8996,9 Major hospital, Copenhagen3.1673,3 Major hospital, province8.9405,9 Major hospital, province5.8014,5 Other major / minor hospitals ,1 Total ,4 Discharges 2009, DkDRG 2010

4th Nordic Casemix Conference, Helsinki 2010 Discharges MDC 14 – no. of diagnoses Hospital no of discharges Average no diagnoses Rigshospitalet, Copenhagen4.6944,3 University hospital, province4.1178,7 University hospital, province6.8475,5 Major hospital, Copenhagen5.8996,9 Major hospital, Copenhagen3.1673,3 Major hospital, province8.9405,9 Major hospital, province5.8014,5 Other major / minor hospitals ,1 Total , Total no of diagnoses 5,4 => ,3 => Discharges 2009, DkDRG 2010

4th Nordic Casemix Conference, Helsinki 2010 Quality and creativity in coding 1. You should be able to code what you do! 2. It should be easy to find the codes! 3. Cooperate with the medical associations! 4. The DRG classification must not provide incentives to poor coding! 5. Clear and transparent DRG classification! 6. Ongoing evaluation of the quality of coding!

4th Nordic Casemix Conference, Helsinki November Thank you Thank you! Jens Lind Knudsen