DRG claims present a unique set of challenges for payers‘ claims (APOSTROPE WAS IN THE WRONG PLACEMENT). Instead, correcting the errors requires a complex and technical approach of selecting potential errors based on guideline based criteria and a multitude of technical factors which may be suggestive of errors. Recommendations for correction are arrived at by applying The Official Guidelines for Coding and Reporting set forth by the four regulatory cooperating parties ICD-10 (CMS, AHA, AHIMA, and NCHS).

  • Extensive and complex coding guidelines, along with yearly CMS updates and changes to the Official Guidelines for Coding and Reporting, and quarterly updates of AHA Coding Clinic advice.
  • Broad variances in hospital coders’ education and competencies.
  • Increasingly higher production goals for hospital coders, associated with higher expectations for revenue cycle management. Widespread “documentation improvement” initiatives by hospitals that may lead to over-stating of diagnoses and procedures.
  • Use of “optimizing” coding software.
  • Clinically unsupported diagnosis documentation that coders are obliged to assign codes for in accordance with their governing guidelines, so that correction can only be achieved by clinician level intervention.