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Clarity through clinical validation
We offer DRG Clinical Validation audits designed to give you an accurate picture of whether the diagnoses reported on your inpatient claims are fully supported by the clinical documentation. With heightened payer scrutiny and aggressive post‑payment audits, it is more critical than ever to ensure that DRG assignment is defensible, compliant, and supported by the medical record—before it is challenged by a RAC or commercial payer.
The sample of the audit includes:
- Validation of Principal and Secondary Diagnoses against established clinical criteria
- Verification of documentation supporting CC and MCC assignment
- Review of consistency between physician documentation, clinical indicators, diagnostic testing, and treatment
- Identification of diagnoses that are unsupported, weakly supported, or clinically conflicting
- Review of DRG assignment accuracy based on validated diagnoses, procedures, discharge disposition and POA indicator assignments
- Evaluation of provider query practices related to clinical validation
Based on the audit results, information is presented to provide:
- DRG assignment as coded by your facility compared to DRG assignment validated by HCCS
- Identification of clinical validation risk areas and denial vulnerabilities
- Analysis of provider documentation practices impacting DRG severity and reimbursement
- Analysis of coding and clinical validation trends
- Financial impact of DRG changes identified through the clinical validation process
- Targeted education and recommendations to improve documentation quality and defensibility
Clinical validation errors are far more common than many facilities realize and represent a significant compliance and financial risk. A single unsupported diagnosis can result in a DRG downgrade, repayment demand, or expanded audit activity. Identifying and addressing these issues proactively helps protect revenue, reduce denials, and ensure accurate reimbursement. Our audits focus on supporting appropriate DRG assignment through clinically sound, well‑documented care—reinforcing why our company standard of 95% accuracy is essential in today’s audit‑heavy environment.
Our coding is provided remotely and how our clients wish us to access their charts varies on a case-by-case basis, so we are completely flexible in this regard. If our client has an EHR, we can remotely access medical records through a VPN or CITRIX environment. If not, we can utilize our Document Management System, ChartStream™, which is a next generation, fully scalable, multi-redundant, web based chart transportation and management system.
As an added bonus, many of our clients use ChartStream™ to facilitate EHR implementation since ChartStream™ provides our clients with electronic images of their charts which can be archived, imported/exported, etc.
- The number and types of charts coded
- The number and types of charts audited
- The account number of each chart audited
- The audit results detailing both overall coding and reimbursement coding accuracy
- The ability to examine the auditor's report on any or all of the audited charts
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