CMS Discloses DRG Coding Vulnerabilities for Inpatient Hospitals

James Carroll, for HealthLeaders Media , July 6, 2011

"Oftentimes, a diagnosis may appear on the discharge summary that may not have been addressed in the medical record (pending test results, etc)," she said. "Best practice is to wait on the complete medical record since rebilling could result in a higher-weighted DRG that will automatically be reviewed by the QIO (quality improvement organization)."

"If internal financial policies lessen their bill hold timeliness then the discharge summary could be available and reviewed by a coding quality coordinator to ensure coding compliance," she said.

When coding claims, if there is conflicting or contradictory information in the record, a coder should query the attending physician to clarify the correct principal and secondary diagnoses, according to the article.

In addition, CMS cites Coding Clinic, First Quarter 2004: "If there is conflicting physician documentation and the coder fails to query the attending physician to resolve the conflict, hospitals are encouraged to code the attending physician's version, but that the failure of the attending physician to mention a consultant's diagnosis is nota conflict."

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