One area of potential cost exposure for payers is inaccurate DRG assignments and reimbursement, which can impact a payer's medical claim spend.

DRG analysts document and accurately report all key components affecting the DRG assignment and associated reimbursement within the medical record, complying with required American Hospital Association Coding Clinic Guidelines and the ICD-9 CM Official Coding Conventions.

How it Works

Analysts first screen DRG claims for codes, or combinations of codes, with savings potential. Next, DRG analysts ensure the diagnosis and procedure codes are accurate and valid based on medical record documentation. If the analyst identifies a coding error, then EquiClaim, an Emdeon company, 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 their coding review, they can refer cases to the inappropriate admission review (IAR) team. Both IAR and DRG review teams work to ensure a proper review for the client, which includes all appropriate documentation and clinical rationale.