Knowledge Base Article

CMS recently released a special MLN Matters® Article for inpatient hospitals, in regards to Recovery Auditors having reviewed a significant number of records for DRG Validation that had an incorrect principal diagnosis. This article focuses on assisting hospitals in identifying key steps to take to avoid unnecessary denials of claims.

CMS has noted that Recovery Auditors review the entire medical record when performing DRG Validation while some hospitals possibly choose to code the record before all documentation is completed. There is a risk when hospitals choose to do this “since they are responsible for reporting codes that accurately reflect the patient’s conditions and procedures. Therefore hospitals may increase their chance of errors by choosing to code the case prior to receiving the complete medical record. Recovery Auditors will not take this into consideration.”

Hospitals are reminded that when there is conflicting or contradictory information in the medical record the attending physician should be queried to clarify the principal and secondary diagnoses. Further, “Coding Clinic, First Quarter 2004 states, 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. However, the failure of the attending physician to mention a consultant’s diagnosis is not a conflict. So, if the consultant documents a diagnosis and the attending physician doesn’t mention it at all, it is acceptable to code it.”

The entire article can be viewed at: http://www.cms.gov/MLNMattersArticles/downloads/SE1121.pdf.