This review of hospital-requested
claim adjustments assures that the correct diagnosis and procedure
information is provided on the adjusted claim form. Thus, the correct
Diagnosis Related Group (DRG) can be determined and the adjustment
difference can be paid by the contractor.
A hospital may file an adjusted
claim. A change in the principal diagnosis or the sequencing of
the diagnoses or procedures may result in a change to a DRG with
a higher weight providing for a higher reimbursement rate. Such cases
should be closely reviewed before the hospital sends the cases to
the contractor for adjusted payment.
When a hospital wishes to submit
an adjusted claim, the hospital must send the case directly to the
contractor to be reviewed within 60 calendar days of the date of
the initial remittance advice. The hospital must provide all of
the following information within the 60-day time frame:
• A copy of the initial remittance
advice;
• A copy of both the original
and updated attestation; OR
• A copy of the original attestation
which has been corrected and corrections initialed and dated by
the attending physician;
• The codes submitted for adjustment;
• An explanation of why the original
codes were submitted incorrectly;
• A copy of the original claim
form (CMS 1450 UB-04);
• A copy of the adjusted claim
form;
• A copy of the medical record
as required for performing admission review and DRG validation;
• If coding changes are based
on newly acquired clinical information, a copy of such information
(e.g., autopsy report).
The
contractor shall check the date on the remittance advice to determine
if the request for adjustment is made within 60 calendar days from
the date of the remittance advice. If the 60 calendar day period
has expired, the contractor shall deny the claim adjustment and
return it to the hospital with a letter explaining the reason for
the denial.
Note: If
all required documents are not provided, the case shall be returned
to the hospital as incomplete. If the required documents are returned
to the contractor within the 60-day time frame, the case shall be
reviewed. If returned after the 60-day time frame, the case will
not be reviewed.
If
the hospital submits a request for a higher weight DRG on a case
that has previously been scheduled for retrospective review, the
case shall be returned to the hospital without review. DRG validation
is performed during routine review procedures.
If
the 60-day period has not expired and all of the required information
has been submitted, the contractor shall use the adjusted codes
to regroup the case to determine if it regroups to a higher weight
DRG. Only adjusted claims that result in a higher weight DRG will
be reviewed. If the case does not regroup to a higher weight DRG,
the case shall be returned to the hospital without review. If the
case does regroup to a higher weight DRG, all required reviews shall
be performed. When potential denial or a coding change other than
that requested occurs, appropriate notice letters shall be issued.
The
Request for Higher Weight DRG Review form has been developed for
use by hospitals in requesting review of higher weight DRG claim
adjustments. This form must be completed and submitted with all
requests. This form has been developed to assist hospitals in assuring
that all required documents are sent with the request for review. Such
requests may only be submitted by hospitals. Vendors
or consultants may not request higher weight DRG reviews.
Any record submitted by these individuals will be returned to the
hospital. ALL REQUESTS FOR HIGHER WEIGHT DRG REVIEW MUST BE RECEIVED
WITHIN 60 CALENDAR DAYS FROM THE DATE OF THE INITIAL REMITTANCE ADVICE.