Medlinks Cost Containment — DRG Validation Servicess

Welcome to Medlinks Cost Containment! With our top-notch DRG validation services, we help clients stay ahead of the challenges impacting healthcare finance.

Each year, CMS releases its inpatient prospective payment system (IPPS) final rule, and when it does, there are always ICD-10 and DRG changes that occur. It is very important to keep on top of these changes because they impact your reimbursement. Failing to do that might mean a substantial decline in your reimbursement. Also, you need to make sure that you have an updated pricer so that your claims are priced outright and you’re ascending and sending correct codes over to Medicare. This ensures that your claims don’t get rejected.

Due to the shift in ICD 10, constraints on physician time, and growing demand for Health Information Management (HIM) assigning DRGs has become much more challenging than ever. Get in touch with Medlinks Cost Containment—your DRG validation specialist for review solutions to minimize the cost of coding errors that lead to inaccurate DRG assignment.

Key Changes in Final Rule 2019 & Their Impact

Let’s take a look at some of the key changes that happened in 2019 and what was their impact.

  • CMS made some changes to the way that the DRGs are grouped, eliminated some, as well as added a few. DRGs were increased from 754 to 759. There were 11 deleted and 17 added to the new DRGs.It impacted vaginal and cesarean section deliveries.
  • There were 435 ICD-10 code changes. 247 new codes were added and 139 revised with 49 deleted codes.
  • CMS added discharge status code 50 and 51 to transfer DRG rule, which is the hospice discharge status codes. In the past, hospice was never impacted by the rule but things changed in 2019 IPPS final rule. If someone was discharged to codes 50 or 51, they would receive the per diem payment — if the stay was below the geometric mean.

CMS IPCC Final Rule 2020

The final rule for 2020 came out in August and became effective on October 1st, 2019. it’s estimated to impact over 3,000 acute care hospitals and almost 400 long-term care hospitals. The final rule came off the proposed changes that CMS posted in April. For the changes that would come up in 2020, they did a review of only the ICD-10 claim data from 2018 med par data. They did not do any MS DRG data examination at all. They looked at resource consumption and patient care costs and that is how they determined what DRGs are going to be added, combined, and eliminated from 2020. And based on the changes that are made, CMS estimated that there will be a 3.4 billion dollar increase in CMS payments over 2019 and that represents a 3.1% increase over 2018.

The first thing to highlight is that the DRGs are staying constant for 2020. There were 28 DRG deleted and 28 that were added in. The main reason behind the change or deletions in these DRGs was transcatheter mitral valve repair with an implant and the peripheral ECMO changes. There are also a few changes from the way that they are grouping pregnancy and childbirth. So those were the DRG changes. As for the ICD-10 codes, 252 new codes were added for the diagnosis codes. More 1,600 procedure codes were deleted for 2020. Some of the changes are particularly in neoplasms, skin and subcutaneous tissues, circulatory system, just to list a few.
There were a couple of changes that also affect the transfer DRG rule. For 2020, there are only 278 DRGs that are going to be impacted by the rule now. So that represents a drop in 2 because, last year, there were 280 that were affected. This is due to all those ICD-10 changes that we mentioned.CMS felt that because of some of the changes, they should not be impacted by the rule. So, the two that were impacted were MS DRG 273 and 274. They’re being removed. And then there were 693 and 694 that are not subject to the rule and they did not qualify for 2020 either. 319 and 320 are also removed.

In the final rule for the fiscal year 2020, there are some heavy-hitters in all specialties that could potentially wreak havoc on organizations’ bottom line. 18 codes were a part of the Z16 category which covered resistance to various drugs. They were changed from Non-CC to CC. Also, the social determinants of health code for homelessness Z59.0 remain as a non-CC designation. The overall relative values for 2020 have increased from those of 2019. If you want more information on the final rule you can get in touch with a DRG healthcare company. Medlinks Cost Containment offers DRG validation as well as coding and compliance services. If you’d like to understand whether or not you’re recovering all of your transfer DRG overpayments and underpayments, take a look at our transfer DRG service.

We are more than just DRG healthcare consulting in the USA; we also offer other services such as:

  • Defense Auditing – We Help You Save Big on Compliance Costs
  • Contract Negotiation Consultation
  • Protected Health Information (PHI)Release Management
  • Complete HEDIS Chases – Record Abstraction, Record Research, Record Overread
  • Claim & Clinical Appeals Analysis — We Provide Payers/Providers The Tools to Connect
  • Payment Integrity — A Two-Pronged Approach to Cost Containment
  • Denied Claim Resolution – Find Solutions to Denied Claims
  • Zero Balance Audits — Increase Reimbursement and Contain Costs

Partner with Medlinks Cost Containment to cut down costs, stay compliant with the laws, and get access to an efficient audit tracking system & integrated medical auditing services.

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