Diagnosis Related Groups (DRG) Validation Re-reviews

7300 – Diagnosis Related Groups (DRG) Validation Re-reviews (Rev. 18, Issued: 10-10-14, Effective: Upon Implementation of ICD-10, Implementation: Upon Implementation of ICD-10) You are responsible for conducting DRG validation re-reviews. The authority for reviewing changes in diagnostic and procedural coding information is found in 42 CFR 478.10(c). A. Applicability Although there are no reconsideration or appeal rights available for changes resulting from DRG validation, the same process used for making a reconsideration determination is used for DRG re-reviews (See §7430). A provider or practitioner dissatisfied with your change to the diagnostic or procedural coding information is entitled to a review of that change if it caused an assignment of a different DRG and resulted in a lower payment (See 42 CFR 478.15(a)(1)). A beneficiary or his/her representative dissatisfied with your change of the diagnostic or procedural coding information is also entitled to a review of that change if it caused an initial denial of a furnished service (See 42 CFR 478.15(a)(2)). Review each case in its entirety. B. How to Request a Re-review The party must file a written request within 60 calendar days after the date of receipt of the notice of change to the diagnostic or procedural coding information. A party may also file such a request after 60 days for good cause (See §7410.C). C. Qualifications of a Reviewer The individual who reviews changes in DRG procedural or diagnostic information must be a physician who meets the requirements in §7420.A. The individual who reviews changes in DRG coding must be qualified through training and experience with ICD coding. The reviewer (physician or non-physician) cannot be the person who made the initial determination (A Registered Records Administrator or Accredited Records Technician must have responsibility for the overall DRG validation process). D. Timing of Re-review Complete your re-review and send a written notice to all parties within 30 working days of receipt of the request for a re-review. E. Notices to Parties Notify all parties (in writing) of your re-review determination. Be specific in explaining the reason(s) for the changes (See Exhibit 7-47) (Do not send this notice to the beneficiary). Notices of re-review must contain the following elements: • A brief statement concerning your duties and functions under the Act, including your responsibility to perform DRG validation; • A listing of the ICD diagnosis and procedure code(s) and narrative description as submitted by the provider and as originally changed by you, along with the reason for the changes; • A brief statement explaining that the provider and practitioner were given an opportunity to provide additional information; • The rationale used in upholding or reversing the initial DRG determination, including the code(s) you finally determined to be correct upon re-review; • A statement that the re-review determination is final (i.e., no further appeals apply); and • The signature, including title, of the medical director or designated physician if the change(s) involve DRG procedural or diagnostic information (i.e., medical judgment). If the change(s) involve(s) DRG coding errors, the re-review notice may be signed by the medical director, designated physician, Chief Executive Officer, Accredited Record Technician, or Registered Record Administrator (See §7115.C.15).