DRG CodingQIO Procedural Transmittal DRG Validation Review ProcessQuality Insights will notify hospitals of any coding corrections, deletions or changes in code sequencing made during the validation process that change the DRG. Quality Insights’ DRG Coordinator is responsible for all technical coding changes, as well as overall DRG validation.
If the DRG validation depends upon medical judgment, the case will be referred to a Physician Reviewer of the same specialty as the attending physician when possible.
When the DRG Coordinator and, or the Physician Reviewer, identifies a potential error which will effect DRG assignment, a Notice of Potential DRG Change will be sent to the hospital and the attending physician. The hospital, or the attending physician, will then have 20 days from the date of the notice to provide additional information, either verbally or in writing
If no additional information is received by the response date indicated on the notice, a Final DRG Change will be issued. A copy of this notice will also be sent to the Fiscal Intermediary (FI) for payment adjustment.
If the hospital or attending physician responds to the potential notice within 20 days, the DRG Coordinator will review the response for technical coding errors, while a Physician Reviewer will review cases that call for medical judgment. In most instances, the physician will be the same one who reviewed the case initially. If the review confirms the DRG error, Quality Insights will issue the Final DRG Change as noted. If no DRG error exists, the hospital and attending physician will be notified accordingly.
If the changes result in a lower weighted DRG, the hospital or attending physician has 60 days from the date the notice is received to request a re-review. The final notice explains this.
As indicated in the final notice, the hospital or attending physician has 60 days from the date the notice is received to request a re-review of DRG changes that result in a lower weighted DRG.