MAS provides detailed audits of DRGs, employing qualified AHIMA-certified coding specialists with extensive knowledge of coding systems and coding compliance guidelines. MAS compares the diagnosis codes and all ICD-9 procedure codes to ensure that the correct DRG was assigned.

MAS reviews all paid claims data based on specific criteria to identify claims of interest that contain:

  • One day lengths of stay with specific diagnoses
  • Lengths of stay inconsistent with severity of assigned DRG
  • Assigned DRGs inconsistent with the type of services received
  • DRG assignments with a cc or MCC; these are reviewed for possible error in diagnosis assignment

In addition to these criteria, MAS analysts run “what if” payment scenarios with claim data to determine possible alternative DRG assignments.

For claims that MAS finds lacking in documentation to support the submitted DRG, or that are found to have received inappropriate inpatient admission status, MAS contacts the hospital to discuss DRG change or inpatient status change. The hospital may either agree with MAS’ new DRG assignment or will submit to MAS documentation supporting the hospital’s original DRG. When this process results in a DRG re-assignment, MAS will send a DRG Rationale Report to hospital representatives indicating that all parties agree with the DRG change, all but precluding the possibility of further appeal.

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