DRG Validation

DRG Validation. H.H.C. Group Can Help.

The DRG (Diagnosis-Related Group) on an inpatient hospital bill (claim) determines the cost of care. DRGs are calculated based on the specific diagnosis (what's wrong) and procedure (what was done) codes on the claim.

ICD (International Classification of Diseases - 10th version) codes describe the patient's disease, illness or injury. American Medical Association's CPT (Current Procedural Terminology) codes depict the actions undertaken.

DRG Validation. H.H.C. Products Get the Job Done.

Healthcare providers nationwide have coders who choose the specific codes to put on a claim based on their reading of the medical records. With over 70,000 diagnostic codes and more than 10,000 procedure codes, errors get made. Sometimes the DRG is inconsistent with the procedure and diagnostic codes on the claim. Sometimes the codes on the claim are not supported by the medical records and sometimes the medical records do not accurately reflect the clinical findings.

Errors can result in thousands of dollars of overpayments. H.H.C. offers payers DRG Validation services to ensure the input to the medical records is correct, the diagnostic and procedure codes accurately reflect the medical records and the DRG is consistent with diagnostic and procedure codes on the claims.

Claim Level ValidationH.H.C.'s proprietary software determines the correct DRG based on the procedure and diagnostic codes on the claim and compares it to the DRG on the claim.

Medical Record Level ValidationCertified coders re-code the claim based on the medical records to determine the correct codes for the diagnoses and procedures described in the records. The correct codes are then compared to the codes on the claim and, when different, the appropriate DRG and resulting charge are determined.

Clinical Level ValidationQualified Board Certified physicians review the information on the medical record to determine if the medical record accurately reflects laboratory results and other clinical findings.