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.
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 §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 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
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §20- Payment Under Prospective Payment System (PPS) Diagnosis Related Groups (DRGs)
8. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §§20.1.2.4. B & C, 40.2.4
9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
10. Medicare Program Integrity Manual, Chapter 6- Medicare Contractor Medical Review Guidelines for Specific Services, §6.5.3- DRG Validation Review, §6.5.4 – Review of Procedures Affecting the DRG
11. Inpatient Prospective Payment System (IPPS) Final Rule and Correcting Amendment Tables: https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/fy-2024-ipps-final-rule-home-page
12. ICD-10 Clinical Modification (ICD-10-CM) and ICD-10- Procedural Coding System (PCS) (ICD-10-PCS) Coding Manual, Official Guidelines for Coding and Reporting, and Addendums