DRG (Diagnosis Related Groupings) Validation Program

The DRG (Diagnosis Related Groupings) Validation Program helps ensure that hospitals perform fair and equitable coding, utilization and billing practices.
 
BCBSND is committed to certifying that our claims database represents correct DRGs and payment amounts. To do so, we conduct the following audits:
 
Coding Audit
Reviews inpatient claims reimbursed by DRG payment to identify incorrect coding or billing practices.
 
Level of Care Audit
Reviews hospital claims with a short length of stay to identify appropriate level of care.
 
Readmission Audit
Reviews hospital claims for readmissions within a six-day period for appropriate discharge and completion of acute care. BCBSND considers a case to be a premature discharge when:
  • Signs and symptoms of an acute process are documented but not addressed during the first admission
  • Treatment was initiated but not monitored, evaluated and/or completed prior to discharge
A planned readmission is considered a readmission due to scheduling problems for either the facility or the physician, or a readmission for physician or patient convenience.
 
Transfer Audit
Reviews hospital claims for appropriate transfer/discharge status.
 
DRG Reference Manual
 
All Chapters

PDF IconDRG Validation Audit Program

 
Individual Chapters

PDF IconTable of Contents
PDF IconChapter 1 Overview of DRG Validation Program
PDF IconChapter 2 DRG Validation Advisory Committee (DVAC)
PDF IconChapter 3 Coding Audit
PDF IconChapter 4 Level of Care Audit
PDF IconChapter 5 Modifications to Criteria / Guidelines
PDF IconChapter 6 Readmission Audit
PDF IconChapter 7 Transfer Audit
PDF IconChapter 8 Catastrophic Audit
PDF IconChapter 9 Reconsideration Process
PDF IconChapter 10 Rebilling Process
PDF IconChapter 11 Communication Document Examples