5CHGE - DRG Code Changed to Reflect Actual Service Billed

Published 11/20/2019

5CHGE - DRG Code Changed to Reflect Actual Service Billed Upcode/Downcode

Reason for Denial
The services billed were paid at a higher/lower payment level based on medical review of the records submitted.

To Prevent this Denial
Under the Prospective Payment System (PPS), Medicare reimbursement rates are based on the patient’s health condition and care needs.

  • Submit orders to cover the procedures billed
  • Submit all documentation related to the services rendered

For more information, see the article "Targeted Probe and Educate Progress Update: DRG 291 Heart Failure and Shock with MCC and DRG 292 Heart Failure with CC" on the Palmetto GBA website.