DRG Downgrades by Commercial Payers: Documentation Defense Tactics – MedLearn Publishing
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DRG Downgrades by Commercial Payers: Documentation Defense Tactics – MedLearn Publishing
In the current climate of cost containment, commercial payers are increasingly downgrading MS-DRGs after claims are submitted, not disputing the need for inpatient care, but questioning the clinical support for CCs (complications or comorbidities) and MCCs (major complications or comorbidities). These downgrades reduce reimbursement, often occur quietly, without formal denial letters, and can slip past traditional appeal processes unless hospita…
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