Medicare PROBE for DRG 291
Are any other facilities experiencing a Medicare PROBE for DRG 291 from your Medicare Administrative Contractors? We are receiving denials for DRG 291, and their reasoning is that “The submitted documentation for the majority of the denials didn’t support billing DRG 291 heart failure and shock with MCC. The heart failure diagnosis was used as principal diagnosis and MCC diagnosis. The principal diagnosis should not under any circumstances be duplicated as an additional or secondary Diagnosis. The documentation didn’t support a Major Complication or Comorbidity (MCC) unrelated to the heart failure diagnosis.” They are denying stating that when I11.0 and/or I13.0 is assigned as the principal diagnosis that the secondary diagnosis code from category I50 which specifies the type and acuity of heart failure cannot be used as an MCC. They further state “If a patient is admitted to the hospital for heart failure, entering another heart failure diagnosis may cause the hospital to receive an incorrect MS-DRG assignment and reimbursement for services rendered. The heart failure I50 codes are treated as an identifier code rather than a separate MCC.” They are referencing the Medicare Claims Processing Manual.
The code first note in the Tabular provides sequencing instructions under category I50 to “code first heart failure due to hypertension & heart failure due to hypertension with chronic kidney disease”. CMS determines which diagnosis codes are considered CCs and MCCs. These are not duplicate codes being assigned as the principal and secondary diagnosis codes. Is your facility experiencing similar denials for DRG 291 from your Medicare Administrative Contractors? If so, how is your facility responding to this Medicare PROBE for DRG 291?