Diagnosis Related Group (DRG) Coding Checklist

Published 04/30/2020

Providers can use this checklist as an audit tool to help assure that they are submitting all required documentation.  


Diagnosis Related Group (DRG) Coding Checklist  Yes  No  N/A
Is there a principal diagnosis, all relevant diagnoses, and procedures documented on the claim and coded correctly?      
If the comorbid condition, complication, or secondary diagnosis affecting the DRG assignment is not listed on the hospital claim but is indicated in the medical record, is the appropriate code inserted on the claim form?      
If the hospital already reported the maximum number of diagnoses allowed on the claim form, have you deleted the code that does not affect the DRG assignment and inserted a new code?      
Is there documentation for the billed date of service?      
Is the principal diagnosis coded to the highest level of specificity?      
Is there documentation of the intent to provide services on an inpatient basis?      
Does the diagnosis relate to the current hospital stay and not to an earlier episode?      
Does the documentation support the medical necessity of all diagnosis and procedure codes billed on the claim?      
Was the admission and the procedure medically necessary but the procedure could have been performed on an outpatient basis? (If the procedure was not medically necessary then please refer to CMS Internet-Only Manual Medicare Program Integrity Manual 100-08 Chapter 6 Section 6.5.4.)      
Has there been a delay in discharge? If so then the case can be potentially be reviewed for length of stay. (Please refer to CMS Internet-Only Manual Medicare Program Integrity Manual 100-08 Chapter 6 Section 6.5.6.)      
There has been a change in the DRG following the review and validation period which is now resubmitted in accordance with the Official Guidelines for Coding and Reporting?      

Disclaimer: This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS’s documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.

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