Update: DRG Clinical Validation Audit implementation

In a February Record article, we wrote about the proposed implementation of the Diagnosis-related Group Clinical Validation Audits and asked for facility input. Based on that input, we’re providing some additional information below:

• Change Healthcare** clinical review of the physician documentation will determine if the patient diagnosis is consistent with the clinical documentation in the medical record. These claim rules align with Blue Cross Blue Shield of Michigan policy.
• According to guidelines from the Centers for Medicare & Medicaid Services, DRG clinical validation is a separate process from DRG coding validation. DRG coding validation involves a clinical review of a case to determine whether the patient has the conditions that were documented. Because this is a clinical DRG validation audit, it should be performed by a clinician or a clinician with approved coding credentials and doesn’t require a certified coder.
• Adding this type of audit won’t increase the number of audits a hospital is subject to as we have established inpatient audit limits. Since we aren’t auditing additional claims, there shouldn’t be an increased administrative burden.
• As DRG clinical validation is a separate process from DRG coding validation, it’s possible to have a claim that is correctly coded based on national coding guidelines, but where the clinical indicators aren’t met.
• DRG clinical validation audits will exclude hospitals who have prospective rate agreements.

Following Blue Cross Blue Shield of Michigan’s review of facility input, we’ll be moving forward with this program, effective Aug. 1, 2022. Details about the DRG Clinical Validation Audits were presented at the May 16 Staff Liaison Group meeting, which included leadership from the Michigan Health and Hospital Association and Blue Cross, and the PHA Advisory Committee on June 21.

**Change Healthcare is an independent company that contracts with Blue Cross Blue Shield of Michigan to provide audit services.