DRG Validation

DRG validation is the process of confirming that the services provided match the billed DRG code. Mistakes in this process can result in underpayments. If a less complex service is inaccurately billed under a DRG code, the payer will reimburse at a lower rate. Additionally, DRG validation considers the patient's complications or co-morbidities, which can increase the reimbursement. Failure to correctly code or record these conditions can lead to lower-weighted DRG assignment and underpayment. Missing diagnosis codes can also cause underpayment as they make the service appear unnecessary. Incorrect use or omission of modifiers can result in underpayments or claim denials. Medical coders frequently overlook the use of modifier 59, which indicates multiple procedures during one visit, often leading to service bundling. It is important to use accurate modifiers to avoid bypassing insurance edits.