0001 - Inpatient Hospital MS - DRG Coding Validation

Issue Name
0001 - Inpatient Hospital MS - DRG Coding Validation
Date
Review Type
Complex
Provider Type
Inpatient Hospital
MAC Jurisdiction
All A/B MACs

Description 

MS-DRG Coding requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate MS-DRGs for principal and secondary diagnosis and procedures affecting or potentially affecting the MS-DRG assignment. Clinical Validation is not permitted.

Affected Code(s)

All MS-DRGs (001-999)

Applicable Policy References

1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor;  and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
4. 42 CFR §405.986- Good Cause for Reopening  
5. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests
6. Medicare Program Integrity Manual, Chapter 6- Medicare Contractor Medical Review Guidelines for Specific Services, §6.5.3- DRG Validation Review
7. CMS QIO Manual Section 4130
8. ICD-10 CM Coding Manual
9. ICD-10 CM Addendums 
10. ICD-10 CM Official Guidelines for Coding and Reporting, and Addendums
11. ICD-10 Procedural Coding System (PCS) Coding Manual,  Official Guidelines for Coding and Reporting, and Addendums 
12. Coding Clinic for ICD-10-CM and ICD-10-PCS