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QIO TRANSMITTAL SERIES ISSUE: DRG Validation Review Process - Printable
pages The Foundation reviews the diagnoses and
procedures reported on the claim to ensure that the diagnostic and procedural
information is documented in the medical record, is based upon accepted coding practices and results in the correct
DRG assignment. REQUIREMENTS
FOR REPORTING DIAGNOSES AND PROCEDURES ON CLAIM Principal
Diagnosis The principal diagnosis is the condition
established after study to be chiefly responsible for occasioning the
admission of the patient to the hospital for care. Secondary
Diagnoses Eight secondary diagnoses should be
reported (if present). However, the
diagnoses do not need to be listed in a particular sequence because the
GROUPER program will search through all secondary diagnoses listed when
assigning the DRG. When more than eight secondary diagnoses
are present the following hierarchy should be applied for determining which
diagnoses are to be reported: 1.
Comorbidities,
complications or secondary diagnoses that affect DRG assignment. 2.
Other comorbidities
or complications related to the principal diagnosis. 3.
Other secondary
diagnoses. Secondary diagnoses to be reported
should represent diagnoses which have the potential for significantly
complicating the management of the patient care and of increasing the risk of
an adverse outcome. Diagnoses that
relate to an earlier episode which have no bearing on the current hospital stay
are to be excluded. While E codes representing the causes of
adverse effects of therapeutic use (E930 - E949) should be reported, other E
codes should not be reported as secondary diagnoses in preference to
reporting secondary diagnoses that represent actual disease processes or
complications. Procedures If there are a greater number of
procedures than can be listed on the claim form (six), the procedures
attested to and reported should be based on the following hierarchy: • Significant procedures that relate
to the principal diagnosis and that affect the DRG assignment. A significant procedure is one that: (1) is surgical in nature, (2) carries a procedural risk, (3) carries an anesthetic risk, or (4) requires specialized training to perform. • Other significant procedures that affect
the DRG assignment. • Other therapeutic procedures; and • Other diagnostic procedures. Hospitals are not required to code other
diagnostic and therapeutic procedures such as: CT scans, physical, occupational, or respiratory therapy, or
radiological procedures. Errors
Found During DRG Validation The Foundation notifies hospitals of
coding corrections, deletions or sequencing changes made during the process
of DRG validation if the DRG assignment is affected. The Foundation employs a Registered Health
Information Administrator who has overall responsibility for the DRG
validation process. When the QIO Case Review Specialist
identifies a potential error during DRG validation review, a notice
describing the proposed change will be sent to the hospital and the attending
physician. In cases where the
determination of an error depends upon medical judgment, the case will be
referred to a QIO Physician Consultant before issuance of a notice. To the extent possible, the Physician
Consultant will be of the same specialty as the attending physician. If the QIO Physician Consultant confirms
the error, a notice will be sent. If
the Physician Consultant feels that there is no error, the Case Review
Specialist will be so informed and no further action will be taken. A verbal or written rebuttal from the
hospital/attending physician within 20 days of the date of the notice is
allowed. If no response to the notice describing the proposed DRG change
is received by the response date indicated on the notice, the Foundation will
issue a final notice. If the hospital and/or the attending
physician responds to the initial notice, the response will be reviewed by
the Foundation's review staff (technical coding issues) or a QIO Physician
Consultant (cases of medical judgment).
This may be the same Physician Consultant who initially reviewed the
case. If the review of the response results in
confirmation of the DRG error, the Foundation will issue the final notice. If the attending physician wishes to
discuss the case with a QIO Physician Consultant, he/she or a hospital
physician representative should contact the Foundation in writing who will
arrange the discussion and issue a final notice if this discussion results in
confirmation of the DRG error. If the hospital and/or attending
physician successfully rebuts the Foundation's determination of a DRG error,
the hospital and/or attending physician will be so notified. For cases involving apparent data entry
errors, the hospital will receive a final notice only. If the hospital feels the data entry
error was not made by the hospital, the hospital may forward a copy of the
original claim sent to the Fiscal Intermediary for the Foundation's
re-review. As stated in the final notice, the
hospital/attending physician has the right to a re-review of any DRG error
resulting in a lower weighted DRG if the request for re-review is submitted
to the Foundation office within 60 days of receipt of the final notice. November 2002 Next Chapter: Hospital Request for
Higher Weighted DRG |
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Copyright © 2005 Northeast Health Care Quality Foundation, all rights
reserved |
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