Higher-weighted DRG case review

When hospitals request a higher Diagnosis-Related Group (DRG) payment, Acumentra Health, as a Medicare Quality Improvement Organization (QIO), is required by Titles XI and XVIII of the Social Security Act to perform a full case review.

Full case review means that QIO clinical staff review the medical record to ensure that the quality of care delivered to a Medicare beneficiary meets professionally recognized standards of healthcare and that the services performed are reasonable and medically necessary. A full case review investigates whether

• medical and surgical services were delivered in the appropriate setting
• diagnostic and procedural information was valid
• DRG assignments were correct
• patient transfers were appropriate
• the quality of care given to Medicare beneficiaries met professionally recognized standards of care
• patients were discharged appropriately
• care provided was appropriately documented

A full case review includes initial screening by a registered nurse and a registered health information technician or administrator (RHIT or RHIA). These coding specialists validate the DRG assignment using applicable AHA Coding Clinics.

Nurses use InterQual^® acute and procedural criteria to review for medical necessity and appropriate level of care. In addition, nurses use Acumentra Health-developed invasive surgical criteria for selected orthopedic procedures not addressed by InterQual procedural criteria.

Admissions that do not pass one or both of these first screenings, or that show a potential quality-of-care concern, are referred to physician reviewers for evaluation. If the physician reviewer determines a potential concern, Acumentra Health sends a letter to the hospital and the physician involved to gather additional information or clarification prior to finalizing the review. Upon completion of the review, Acumentra Health notifies the physician and the hospital of the review results. If the concern is upheld and involves a utilization or coding issue, the Medicare fiscal intermediary is notified for payment adjustment.