Hospitals should calculate their MS-DRG pair or triplet percentage and compare to national and state averages, benchmark organizations, and competitors. This will determine if the documentation and coding should be examined for deficiencies and improved, or if there is a difference in the patient populations. If you are billing for less severe codes than your comparison hospitals, you may be leaving money on the table. Conversely, if you have an unusually low rate of patients with no complications or comorbidities, you may be increasing your risk of an audit.
For those that are still confused about this, many conditions have three billing levels: no complications/comorbidities($), some complications/comorbidities($$), and major complications/comorbidities($$$). The level you bill at is determined by what clinical documentation you have to support it. You want to bill as high as is appropriate to maximize reimbursement. You might have expensive complicated cases but can't bill high because the documentation isn't there. In that case you want to fix your documentation. Conversely if you are not billing as high as your documentation supports, you are leaving money on the table and should fix billing processes. Lastly, if you only bill major complications (with no simple cases) in order to maximize reimbursement, you risk raising audit flags.
You can do these simple calculations using freely available data from CMS and Tableau Desktop. The overall plan is to create one sheet that lists available DRGs to examine ( which will be your filter). Another sheet shows the triplet percentages for you, and another sheet that shows the percentages for your benchmark (hospital or group of hospitals). Put them all into a dashboard where you can click on different DRG pairs and triplets and compare yourself to whomever.
I like using pie charts to compare percentages (one of the few time they are useful) , but you can use bar charts or even good ol numbers in tables.
Load the CMS Inpatient DRG Data Into Tableau
Im using Medicare Provider Utilization and Payment Data: Inpatient . You can find out a little more about this data in one of my posts here. Because it is only the top 100 DRGs and not all 500-ish of them, it is pretty small and loads into Tableau easily. Here is tableau with the DRG data in there (plus I think I added a few other useful variables).
Create a Table That Lists Your MS-DRGs
Simply drag “DRG-Definition” from dimensions to the “rows” section of a table. See how easy that was? Now you have a nice list of MS-DRGs to choose from in your dashboard menu. Perhaps you want to name this sheet “Menu” or “Select DRGs”. Easy huh?
Create a Pie Chart to Display Your MS-DRG Ratios.
This is going to be pie chart that displays the Total Discharges per DRG Definition. Create a new sheet and call it “You” (or “Us”, or your name, whatever). Drag Total Discharges over to the chart area and make sure you have Pie Chart selected. Change Total Discharges from “Sum” to “Quick Table Calculation” –> “Percent of Total”.
If the percentage numbers are not showing up, click on the “abc123 label” button and “show labels”.
Now, we want it show the percentage of each DRG, so we are gong to have to break up the pie by detail and color. To do this in one step, drag “DRG Definition” onto the “Color” button. Booyah. Now you should have a million DRGs showing on your pie (there is actually only 100 of them but it looks like a lot).
Now we want to show ONLY the data for your hospital. Drag “Provider Name” onto the Filter panel. Under Filter, go to “Select from List” and deselect everyone except for you. Now only your stuff is showing in this pie chart.
Create a Pie Chart to Display the Benchmark MS-DRG Ratios.
At this point you should know who you are comparing yourself to. Do you want to compare to national averages or state averages? Do you have a hospital or group of hospitals that are ‘like’ you that you usually use for benchmarking? Do you want to see what the competition looks like? The answer to this depends on your specific goals. If you have multiple goals, you can do this dashboard with multiple pie charts, each representing a different comparison. However, for this tutorial we are comparing to only one other organization.
Create a sheet exactly like the last step but name it “Benchmark” (or “Them”, or “State Average”, or whatever you are doing). If you are comparing to a single hospital or set of hospitals, then filter on “Provider Name” just like the last step and select the hospital(s) that you want to include for this chart. If you are doing a State average, then filter on state. If you are doing national average then do nothing.
You are almost done!
Create a Tableau Dashboard with DRG as Filter
Drag your two pie charts and your DRG menu onto a new dashboard. Set the DRG sheet to “Use as Filter”. Now arrange the legends and titles so it looks nice. When you click on three DRGs (triplet) or two DRGs (pair) the pie chars will display the pair or triplet percentages for you.
And there you have it! Interpreting this information can be tricky sometimes. But it is a great tool to suggest a closer look at coding and documenting practices so you are billing at an appropriate level and not leaving money on the table.
Let me know if you have any questions or if this post was useful to you.
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