Wiki New to DRG Downgrades

[bluranger23]

Hi everyone I am starting to review drg downgrades and was wondering if it seems right if Aetna would downgrade a claim from 742 to 743 when the assignment is based on Operating room procedures. The claim was billed with the required procedure codes but Aetna downgraded the claim but referenced it was related to 2 diagnosis codes. Not sure how to proceed can someone help

 

[sls314]

Hi everyone I am starting to review drg downgrades and was wondering if it seems right if Aetna would downgrade a claim from 742 to 743 when the assignment is based on Operating room procedures. The claim was billed with the required procedure codes but Aetna downgraded the claim but referenced it was related to 2 diagnosis codes. Not sure how to proceed can someone help

DRG 742 and DRG 743 have the same list of associated procedure codes. Both DRGs are Uterine and adnexa procedures for non malignancy.

The only difference is that DRG 743 is with CC/MCC, and DRG 742 is without CC/MCC. (CC = Complication or Comorbidity, MCC = Major Complication or Comorbidity) You should start your research with the CC and MCC diagnoses.

If the payer has downgraded your DRG from 743 to 742, the payer is telling you that they don't believe that the patient had a qualifying CC/MCC.

If you believe that the documentation supports a complication or comorbidity, then you can appeal the downgrade. If you agree that the documentation doesn't support a complication or comorbidity, then DRG 742 would be the appropriate DRG.

Good luck!