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Providers and HMS debate use of Sepsis‑3 in DRG audits; plan to pilot small sample with clinician review
Summary
HMS presented DRG validation criteria and clinicians raised strong objections about using Sepsis‑3 for coding-based DRG adjustments. HMS and department staff agreed to review a small, blinded sample with clinician experts before issuing preliminary findings.
HMS presented its DRG post‑payment validation process and a broad discussion followed about which clinical definitions and coding rules should govern DRG reassignment.
"For DRG review, we'll review claims to verify that all diagnosis and procedure codes are billed according to the ICD‑10‑CM official guidelines for coding and reporting," Mary Stein, senior director for clinical policy and quality at HMS, said. She listed five elements that HMS will verify, including diagnosis and…
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