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DRG Downgrades: Are Payers Not Allowing Your Diagnosis

Presenter Jennifer R Swindle, CPC, CIC, CPMA, CEMC, CFPC
Broadcast Date 4/15/2026
Time 10:00am PT / 11:00am MT / 12:00pm CT / 1:00pm ET
Presentation Length 60 minutes
Price $65 (Non-members $85)
DRG Downgrades: Are Payers Not Allowing Your Diagnosis Webinar

Learn more about this event

Focused on DRG downgrades when payers are not allowing a diagnosis code. What is needed? Can they be clinically validated? This presentation will focus on some of the most common diagnosis that may be disallowed by the payers, causing a financial hit to the facility, as it often lowers the DRG. The conflict between coding guidelines and what payers may be looking for and the need for provider education.

Learning Objectives/Agenda:

• Understand DRG downgrades, why they happen
• Understand how to appeal and try to resolve some of the downgrades
• Documentation requirements for Sepsis and the difference in Sepsis 2 and Sepsis 3 criteria
• How is respiratory failure often measured by the payers
• Where coding guidelines may conflict and what providers need to know

Why is this topic timely/important?

More and more DRG downgrades seem to be occurring and with an increasing number in downgrades, the financial impact can grow quickly. Hospitals need to be paid appropriately for the services rendered. There is also an expectation that as AI becomes more involved in the denial process, this may increase, so now is the time to put some safeguards in place.

Who would benefit from this topic?

• Medical Coders
• CDI professionals
• Coding managers
• Revenue Cycle Managers
• Denial and/or Follow-Up staff
• Compliance officers

What is the presenter's expertise on this topic?

Certified in both inpatient coding and clinical documentation integrity, also have spent many years working with multiple clients and assisting in fighting these types of downgrades and appealing to gain proper reimbursement.

Jennifer R Swindle, CPC, CIC, CPMA, CEMC, CFPC

About The Author

Jennifer R Swindle, CPC, CIC, CPMA, CEMC, CFPC

Swindle has more than 20 years of experience in the healthcare industry. In her role as vice president of coding and compliance for Pivot Health, she is responsible for identifying and mitigating client risk by assessing, designing, and implementing proven compliance protocol. Swindle is highly credentialed as an auditor, but also has vast expertise as an educator and facilitator for both large and one-on-one sessions. She has written numerous articles on coding practice in AAPC the Magazine (formerly Coding Edge and Healthcare Business Monthly) and Healthcare Financial Management Association’s Revenue Cycle Strategist.

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Two ways to register for this event
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