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Hospitals submit requests for higher-weighted DRG assignment to their Intermediary for processing and payment. Requests granted by the Intermediary are selected by the Centers for Medicare & Medicaid Services (CMS) for Quality Improvement Organization (QIO) review on a post-payment basis.
As the QIO, we verify the accuracy of the hospital's ICD-9-CM coding of all diagnoses and procedures that affect the DRG.
When reviewing hospital-requested higher-weighted DRG assignments, WVMI performs a medical necessity review and DRG validation.
WVMI will notify hospitals of any coding corrections, deletions or changes in code sequencing made during the validation process that change the DRG. Read about errors for more information.
If the DRG validation depends upon medical judgment, the case will be referred to a physician reviewer of the same specialty as the applicable physician when possible.
If WVMI identifies a potential coding error, the hospital and applicable physician will be alerted.
We offer guidelines for hospitals to follow in requesting a higher-weighted DRG.
Questions about coding? Contact us.