Denial Related to Principle Diagnosis / Federal Registry
I'm currently appealing a denial where the insurance wants to flip the PDX into the lower paying DRG. (Cellulitis vs Heart Failure). Both were equally treated.
I know there is a statement in the Federal Registry by CMS stating they fully understand and support hospitals sequencing the higher paying DRG when it meets the definition of the principle.
Does anyone know the date / or pages in the Federal Registry where this is located. I want to use this in my appeal. I had a copy of the regulation but have lost it.
Thank you
Comments
I think you might be looking for this:
“we do not believe there is anything inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment as long as the coding is fully and properly supported by documentation in the medical record (FY 2009 IPPS final rule)”
I found this in the article from ACDIS below that might be helpful to you as well.
https://acdis.org/articles/note-acdis-director-latest-oig-report%E2%80%94alarm-bells-or-much-ado-about-nothing
page 74
DEPARTMENT OF HEALTH AND HUMAN SERVICES (cms.gov)
Thank you! I have also been looking for this statement!