DRG validation is a tool that can be used to reduce risk, defend claims, and ensure the accuracy of the coded items. The purpose of DRG validation is to confirm that diagnostic, procedural information, and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician’s description and the information contained in the beneficiary’s medical record. Auditors are charged with the task of validating principal diagnosis, secondary diagnoses and procedures affecting or potentially affecting the MS-DRG. This is where DRG validation can be utilized.

One area of potential cost exposure for provider hospitals is inaccurate DRG assignments and related reimbursement, which can negatively impact a providers medical claim spending. Auditors and QA professionals capture lost revenue and review for accuracy on a post payment basis or concurrently for the client. DRG analysts document and accurately report all key components affecting the DRG assignment and associated reimbursement within the medical record, complying with required American Hospital Association Coding Clinic Guidelines and the ICD-9 CM Official Coding Conventions.

Let us begin dissecting the components of the DRG, with expansion of detail and application in newsletters to follow. At the very beginning of this process is the identification of the Principal Diagnosis:

The definition of a Principal Diagnosis is the diagnosis which, after study , is determined to have occasioned the admission to the hospital.

The Secondary Diagnosis is all conditions that exist at the time of admission or that develop secondarily that affect the treatment received or the length of stay.

Example: John Smith has a principal diagnosis of cholecystitis but develops atrial fibrillation during this hospitalization and requires a cardiology consult and cardizem drip to control the rate. Atrial fibrillation is assigned as the secondary diagnosis.

Principal Procedure: Procedure performed for the definitive treatment rather than for diagnostic or exploratory purposes, or that was necessary to treat a complication, usually related to the principal diagnosis. John Smith has cholecystitis with cholelithiasis and has a laparoscopic cholecystectomy.   The laparoscopic cholecystectomy is the principal procedure. The procedure will move from a Diagnosis DRG to a Surgical DRG (usually higher paying), with increased length of stay and higher relative weight.

Major Comorbid Condition (MCC)   Diagnosis codes that reflect the highest level of severity and have the potential to increase reimbursement. Examples of MCC’s are: 415.0 Acute Cor Pulmonale, 428.21 Acute Systolic Heart Failure, 348.30 Encephalopathy, Unspecified.

Complication/Comorbidity (CC) A condition that, when present, leads to substantially increased hospital resource use, monitoring, and increased complex services.   Examples of CC’s are: 269.3 Unspecified malnutrition, 560.31 Gallstone Ileus, or 292.81 Drug induced Delirium.

Relative Weight. An assigned weight that is intended to reflect the relative resource consumption associated with each MS-DRG. The higher the relative weight, the greater the payment to the hospital. The relative weights are calculated by CMS and published in the final prospective payment system rule.