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HMS and providers debate sepsis definitions as part of DRG validation; department to use clinician‑led small sample reviews
Summary
HMS reviewed DRG validation criteria and cited ICD‑10 guidance and clinical references; clinicians on the call debated Sepsis‑2 versus Sepsis‑3 definitions and urged clinician judgment. HMS and the department agreed to clinician‑led reviews of a small sample before issuing preliminary findings.
Mary Stein, senior director for clinical policy and quality at HMS, described the DRG validation process HMS will use for post‑payment review of acute inpatient claims, emphasizing a combined coding and clinical validation approach that follows ICD‑10 official guidelines and relevant coding clinics.
She listed five review elements HMS will verify: accurate diagnosis coding, accurate procedure coding, discharge status codes, present‑on‑admission indicators and clinical documentation/supporting diagnostic testing. HMS said…
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