Heart Failure and Shock Diagnostic Related Grouping (DRG codes 291-293)

Published 10/15/2020

This Comparative Billing Report (CBR) focuses on providers who submit claims for Heart Failure and Shock Diagnostic Related Grouping (DRG codes 291–293). CBR information is one of the many tools used to assist individual providers in becoming proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare guidelines.

Palmetto GBA has partnered with MCG, to proactively inform the provider community in regards to the implementation of care guidelines alongside data analysis to increase efficiency and lessen the need for readmission for same/similar diagnosis.

MCG’s Inpatient & Surgical Care guidelines provide evidence-based criteria and other tools for efficient review of utilization and documentation of medical necessity, making it a valuable resource for proactive care management and assessment of patients facing hospitalization or surgery. The guidelines are designed to be used in conjunction with a provider’s clinical judgment. Please visit MCG’s website for additional information at http://www.mcg.com.

For your personalized Heart Failure and Shock DRG results log on to eServices.

Heart Failure and Shock Diagnostic Related Grouping (DRG’s 291–293) Defined  

DRG Code
Heart Failure and Shock with Major Complication/ Comorbidity
Heart Failure and Shock with Complication/ Comorbidity
Heart Failure and Shock without Complication / Comorbidity or /Major Complications/ Comorbidity

Webinar: Heart Failure (DRG 291-293) Webinar

The metrics reviewed in this CBR are the utilization for each DRG category and readmission rates in comparison to peer groups in the state and the jurisdiction. This report is an analysis of Medicare Part A claims extracted from the Palmetto GBA data warehouse.

A provider is considered to have a re-admission when a beneficiary has been admitted to a hospital under any diagnoses within 30-days after discharge from heart failure diagnoses under his care. The re-admission rate is calculated as number of re-admission over number of all admissions during the past six months. For the purpose of this CBR, “peer group” is defined as other providers in Jurisdiction M (JM) that have billed the grouping of DRG codes. The analysis shows the portions of your Heart Failure and Shock DRG claims at each level compared to your peers in JM.

Example of eCBR Results from eServices

Example of eCBR Results from eServices

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