The Centers for Medicare & Medicaid Services have introduced a number of new payment initiatives that will have a profound effect on hospital reimbursement, quality and safety ratings. The new medical severity diagnosis–related group (MS-DRG) payment system adds a number of new DRG categories to more adequately account for patient severity.

Thousands of dollars are lost each year due to poor DRG selection and under-coding. Understanding the complete DRG process is key to determining the amount of appropriate reimbursement. Accurate DRG assignment and auditing practices help you prevent both up-coding and under-coding, saves money and shortens the revenue cycle. Hence a comprehensive DRG compliance audit is required to ensure appropriate coding & reimbursement to the providers.

How can Data Marshall Help?

Data Marshall’s Payment Integrity Audit operations will work with you to define a sampling plan that meets the audit’s objectives. DRG Analysts will review the Medical records to ensure that appropriate ICD-9-CM diagnoses and procedure codes are supported in the medical records. If the analyst identifies a coding error, then Audit and Recovery Services assigns a revised DRG and submits it to the provider for approval. If the submitted documentation supports the original DRG, the client receives a final disposition indicating the original DRG the provider assigned is accurate.

If a DRG analyst identifies a potential medical necessity or coverage issue during the coding review, they can refer these cases to the inappropriate admission review team. Both the teams work to ensure a proper review for the client, which includes all appropriate documentation and clinical rationale.

Data Marshall has expertise in auditing the following DRG systems

• Medicare DRG (CMS-DRG & MS-DRG)
• Refined DRGs (R-DRG)
• All Patient DRGs (AP-DRG)
• Severity DRGs (S-DRG)
• All Patient, Severity-Adjusted DRGs (APS-DRG)
• All Patient Refined DRGs (APR-DRG)
• International-Refined DRGs (IR-DRG)

Benefits

• Identify financial and coding impact
• Safeguard cash flow
• Protect operational efficiency
• Improve Documentation and coding practices
• Reduce legal and financial liabilities

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