Hospitals may submit requests for Higher-Weighted DRG assignments directly to their fiscal intermediary for processing and payment. All such requests granted by the intermediary are subsequently selected by CMS for QIO review on a post-payment basis. As specified in
42 CFR §412.60(d)(2) and
42 CFR §476.71 QIOs review hospital-requested higher-weighted DRG assignments for medical necessity, quality and DRG validation. The purpose of DRG validation review is to ensure that the diagnostic and procedural information and the discharge status of the patient matches both the attending physician’s description and the information contained in the patient’s medical record. Adjustments reported by the QIO have no corresponding time limit and are adjusted automatically by the intermediary without requiring the hospital to submit an adjustment bill.
