Medical coders and billing professionals routinely use Diagnosis Related Group (DRG) codes when submitting claims to Medicare or other payers. DRG codes are organized according to bodily systems and medical procedures. In general, the more serious a patient’s illness and treatments, the higher the “weight” of the DRG code which measures resource utilization. DRG weighting is based on a mathematical calculation that assigns an average cost for a given treatment. The calculation is then adjusted to account for regional differences in costs and other factors. DRG coding helps ensure equitable payments across a variety of patient conditions and locations.
While hospitals submit initial claims for inpatients stays with DRG codes, sometimes it becomes necessary to resubmit the claim with a higher weighted DRG code as a correction to the original claim. For example, this situation can occur when a complicating condition affecting the patient’s treatment was omitted on the initial claim. Submitting an adjustment to the claim that results in a higher-weighted DRG code is a trigger for a potential review of an inpatient claim. This review activity helps ensure that the patient’s diagnostic, procedural, and discharge information is coded and reported properly on the hospital’s claim and matches documentation in the medical record.
Higher Weighted DRG Review Department Helpline: 844-740-7122