DRG Documentation Deck 2012

The Medicare MS-DRG system expands the number of DRGs and heightens the need for detailed documentation to support DRG assignments. But the key to appropriate documentation is the clinician who must record specific facts and events into the medical record. The DRG Documentation Deck was created to give clinicians and coders a quick reference to what the Medicare program requires and what elements are necessary for optimal reimbursement.

Key Features and Benefits:

• Quickly reference documentation requirements for 50 key medical conditions that have the greatest impact on hospital reimbursement. Organized and color-coded by body system, these pocket-sized reminders help physicians and coders understand documentation requirements.
• Optimize DRG assignment. Understand documentation requirements to move non-specific diagnosis codes to more specific related diagnosis codes that are designated as CCs or MCCs. 
• Learn where to look. Suggests where to look in key source documents for clinical evidence supporting MCC (major complications and comorbidities) and CC (complications and comorbidities).
• Understand clinical indicators. Know the clinical events and circumstances that confirm higher patient severity that translates to CC and MCC conditions.
• Know typical treatments. Each card identifies the typical treatments, noting the most common modalities, and also describes the care options found in more severe cases.
• MS-DRG basics. Introductory cards describe grouper logic and provide definitions for key terms.
• General documentation tips. Learn how to "rule out" diagnoses, use of symbols and abbreviations, documenting findings from lab and radiology tests, etc.  
• List of most commonly missed CC/MCC conditions.
• Documentation examples. Learn from examples of non-specific documentation such as CHF and related specific documentation such as acute or chronic diastolic CHF.

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