Hospital manipulations in the DRG system: A systematic scoping review

Background: In the Diagnosis Related Group (DRG) payment system, hospitals are usually suspected of 'DRG creep,' which has been narrowly regarded as reporting diagnostic and procedural codes that result in larger reimbursement. Objective: This review was aimed to systematically explore ways in which hospital manipulations of DRG coding may occur. Methods: A systematic scoping review was conducted using MEDLINE, EMBASE, Web of Science, EconLIT, Proquest Digital Dissertation and Theses, Conference Proceedings, and Thai Index Medicus, using appropriate search strategies. Based on predefined criteria, each article abstract was screened by two screeners with good inter-rater reliability. The included articles were qualitatively explored using thematic content analysis. Results: Hospital manipulations of the DRG system can be categorized into three groups: corporate, clinical, and coding practices. Corporate includes all activities not directly related to patient care; possible manipulations are focused on hospital management, administration, or finance and therefore are the responsibility of the executive board or hospital director. Clinical manipulation deals with activities in the care process and is the responsibility of health care professionals. The last group covers conventional definition of DRG creep that focuses on documentation and coding. Conclusion: Hospital managers who deal with the DRG payment system should be aware that DRG creep is not merely about upcoding. Indeed, the DRG system can be manipulated by hospitals in three different approaches, the so-called "3C": corporate, clinical, and coding practices.