Coding Validation

For claims reimbursed by DRG, the validation and prioritization of the ICD-9 diagnoses and ICD-9 procedure codes, in addition to other factors such as disposition code and birth weight, may have a significant impact on the amount of reimbursement. NYCHSRO/MedReview’s DRG Coding Validation program ensures that no “upcoding” occurred in the assignment of the DRG.

WHAT IT IS:

  • A post-discharge (either before or after payment) review program which:

    • using proprietary NYCHSRO/MedReview criteria, screens the provider submitted DRG

    • determines whether the claim represents a potential for “upcoding”

  • Reviews medical chart documentation to determine whether the appropriate DRG was assigned and submitted for payment by the provider

  • For claims with incorrectly submitted DRGs, regroups the claim, utilizing appropriate regrouping software, to the proper DRG and advises payer accordingly

HOW IT WORKS:

  • Claims payer submits, either prior to or after payment, an electronic claims file indicating the DRG reimbursement for inpatient payment, which are then subjected to the following:

  • Focused Inpatient DRG “Upcoding” criteria selection

    • Utilizing NYCHSRO/MedReview’s state-of-the-art proprietary screening criteria, claims are screened and those meeting the criteria of potential for AP and/or MS DRG upcoding are identified for further review

  • Coding Validation

    • Medical chart documentation is requested from providers for selected claims and NYCHSRO/MedReview’s RHIA, RHIT or CCS coders review the data to determine whether the chart validates that the billed diagnosis and procedure codes are properly documented

    • Miscoded claims are regrouped, a reassigned DRG determination is made and the payer is notified of the correct DRG and estimated payment to be made for that revised DRG

For more information, click here.