DRG 312 Reviews Put Providers 'In a Squeeze'

"With rehab claims [during the demonstration] we lost the whole payment and were only able to recoup the ancillary services—they took back $11,000 to $15,000 and we were able to rebill for only hundreds—and there was no downcoding of the CMG (case-mix group) either; they either met criteria or did not," she says. "I fear the same is true with this new round of PPR [prepayment review] because their focus is on the short stay (1–2 day) admits, looking to see if patients met inpatient criteria."

She continued, "If not, they won't downgrade the DRG, they will deny the entire DRG payment."

What should providers do? First, they need to pay close attention to what the Kentucky and Ohio probe shows, says Beckley. CGS explains in its notice the reason for denials for DRG 312, and also presents some advice going forward. Of the 79.9% denial rate, a significant percent (73.2%) is made up of denial code 5J504. The CGS notice states the following about 5J504:

Reason for denial

• Documentation did not support medical necessity
• Denial code 5J503 (3.7%),
• Denial code 56900 (2.7%),
• 5CHGE – DRG up code/down code (0.1 %).