Medical record review of the following DRGs, identified services as not medically necessary for the inpatient settings billed.
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However, this was an efficient method through which to group a patient to DRG 462 for rehabilitation.
Rehabilitation facilities excluded from the DRG payment methodology also were instructed to use this code to indicate principal diagnosis.
The IRF PAI instructions for code assignment mandated the etiology-advised coders to report the diagnostic code for the acute condition that was responsible for the impairment.
This was unusual, and ran contrary to how the official guidelines instructed coders to operate.
The Centers for Medicare and Medicaid Services (CMS) reminds providers that the medical record must contain sufficient documentation to demonstrate that the beneficiary’s signs and/or symptoms were severe enough to warrant the need for inpatient medical care.
To assist in lowering DRG claim errors, providers are reminded to accurately document the medical necessity of services, code correctly and ensure that care is provided in the appropriate setting.
When coders for inpatient rehabilitation facilities were instructed to use a code from the V57series to indicate principal diagnosis, there was a loud howl of protest from those who felt that these codes did not represent diagnoses but rather the treatment a patient would receive.
It was inconsistent, as staff did not report a code to admit for medical care or a code to admit for surgery.
Medical record review conducted by the Comprehensive Error Rate Testing (CERT)and Recovery Audit programs identified errors related to Diagnosis-Related Groups (DRGs).