- Last Active
- MS-DRGs without mcc/cc OR MS-DRGs with cc looking for a mcc
- Do not send accounts already reviewed by CDI on day of discharge or day prior to discharge.
- MS-DRGs with a single mcc or cc that impacts the DRG
- All accounts where the clinical criteria for the only cc or only mcc diagnosis that impacts the DRG if the supporting clinical criteria is not documented in an Optum CDI comment and/or CDI query should be sent for second level review. The inpatient coder should add “Only CC” or “Only MCC” in the comment field.
- The CDI Specialist will only review the cc/mcc diagnosis to determine if the clinical criteria have been met.
- APR-DRGs with a single diagnosis impacting the SOI
- Inpatient coders should add “SOI” in the comment field. (same process as number 2)
- DRG mismatch
- Do not send accounts to CDI to review if subsequent documentation was added after the last CDI review that resulted in a DRG mismatch.
- All mortality accounts less than 4/4 (Includes CAH’s)
- Accounts with no CDI review, if you would like a second opinion and is not included in numbers 1-5.
- Accounts excluded from second level reviews:
- Healthy elective (scheduled) joint replacements without mcc regardless of LOS
- Behavioral health
- Critical Access Hospitals
- Pediatric patients
- All healthy surgeries (No chronic conditions, LOS as expected, no complications, ect.)
- 1 day stays, not included in numbers 1-5
You can always reach out to CDI for a second level review on any case you would like a second opinion no matter if the account is excluded from reviews.April 2