Experience with DRG Downgrades, particularly Tri-Care (Military)

morris-jeff@CooperHealth.edumorris-jeff@CooperHealth.edu
in Pediatrics

Hi, Just wanted to reach out and see if anyone has any experience with Tri-Care downgrading DRG's? If so, how did you appeal? We received notification from our business office stating "Tri-Care states this account was billed under DRG 790 but they are downgrading to DRG 612". This is a neonate and it appears that DRG 612 is an APR DRG, so that's not even comparing apples to apples. The documentation and coding support both DRG 790 and the APR that was assigned. The infant was less than 24 weeks, less than 500 gr and had RDS with surgical procedures, etc.. The APR they are citing is for a larger infant. There is no official letter, just notice of the DRG downgrade.

We were thinking the best thing to do was to defend DRG 790 with the documentation and coded dx's that map to that DRG per the DRG expert but not sure how to include that we feel DRG 612 is an APR and that it's not the appropriate APR based on birth weight.

Thanks, Jeff

Comments

  • morris-jeff@CooperHealth.edumorris-jeff@CooperHealth.edu

    Did a deeper dive into this particular payer and found that they have their own set of DRG's. They do have a DRG 612 and it appears appropriate for this infant because it has a RW of 18! I am thinking that there might be some confusion in our business office related to this and not a true DRG issue.

    Jeff

  • jackietouch@aol.comjackietouch@aol.com
    Wow...I didn't even know this was a possibility. Thanks so much for this update, Jeff. I am going to keep this is mind if this comes up at our facility.

    Thanks!
    Jackie
  • vbica@nemours.orgvbica@nemours.org
    Tricare does have their own AP DRGs.  We have a whole separate billing for those patients
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