Q&A: Fighting DRG downgrades

Q: We’ve encountered audit takebacks and denials from a certain payer who removed codes and procedures that result in lower DRGs. On one account, a laparoscopic cholecystectomy procedure was removed stating that “the procedure OFT44ZZ could not be validated as relevant to the admission.” The patient had gallstone pancreatitis. Clearly, this was ridiculous and the documentation from the physicians was great. 

Has anyone else seen the practice of removing procedures and codes resulting in lower/different DRG assignment without clinical review? We believe it is due to length of stay (LOS) being lower than the DRG lists. Of course, we appealed and won the case, but this took many resources to fight for a case that was done correctly in the first place. 

In another instance, we had a newborn who was diagnosed as being tongue tied and also had a hydrocele. These conditions were reported and led to a certain DRG assignment. The same payer took those diagnoses off the claim and stated that no resources were used and that they did not impact the LOS. The Official Guidelines for Coding and Reporting state the conditions must be coded, but these codes led to a higher DRG and the payer removed them.

Do you have any advice for fighting or preventing these types of denials?

A: You are not alone with these issues. I would suspect the payers who are doing this are private payers as well.

There are a couple things I would suggest doing (if you’re not already). First, check to ensure the coding is correct per the documentation; ensure you’ve captured all appropriate secondary diagnoses. And then, work with the providers to not just give you the diagnoses, but also discuss the issues related to the patient’s care in their documentation.

For example, if the patient is discharged earlier than anticipated, the provider should both indicate this in the discharge summary and also document why this has occurred. For example, “Due to patient’s overall health and ability to manage pain (or activity, etc.) we were able to discharge her earlier than anticipated. She will have a follow up on (date) and will receive a phone call to ensure she continues well in the healing process…” In other words, “own” the fact the patient is going home early while discussing why you were able to do this despite the extent of the procedure, etc.

You may also want to share these denials with your providers, so that they understand the issues. They might be able to identify arguments to support the procedure or identify documentation needs on their own related to their procedural notes or their concerns for the patient.

Editor’s note: Laurie L. Prescott, MSN, RN, CCDS, CDIP, CRC, CDI education specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps, visit www.hcprobootcamps.com/courses/10040/overview.