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Issue Number - Name
0001 - Inpatient Hospital MS - DRG Coding Validation
Review Type
Complex
Claim Type
Inpatient Hospital
Region and State
RAC 1-4
All States
Date Approved
2017-02-01

Description

Coding requirements: 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 Codes

  • All MS-DRG's (001-999)

Applicable Policy References

  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 6.5.3 A-C 
  • CMS QIO Manual, Section 4130
  • ICD-9 & 10 CM Coding Manual
  • ICD-9 & 10 CM Addendums
  • ICD-9 & 10 CM Official Guidelines for Coding and Reporting, and Addendums
  • ICD-10 Procedural Coding System (PCS) Coding Manual,  Official Guidelines for Coding and Reporting, and Addendums
  • Coding Clinic for ICD-10-CM and ICD-10-PCS