DRG Clinical Validation
Apply physician-led review protocols to reconcile diagnostic and procedural codes with the clinical narrative, proactively identifying unsupported comorbidities to align reimbursement with actual patient acuity.
How We Support Our Clients
Our approach relies on a comprehensive, multi-step process rooted in Reliable Care Organization (RCO) principles.
We prioritize the review of high-risk DRG categories with the highest reimbursement differentials between severity tiers, directing audit resources toward cases with the greatest financial exposure.
We systematically compare coded ICD-10-CM/PCS diagnoses and procedure codes against the clinical narrative to identify discrepancies that undermine the reliability of the claim.
We evaluate whether documented CC/MCC indicators are clinically supported through standardized documentation workflows, ensuring that severity indicators are backed by objective medical evidence.
We deploy independent physician reviewers to assess whether a patient’s documented clinical acuity objectively aligns with the severity level implied by the assigned DRG, providing a defensible clinical-judgment layer to the coding process.
Ready to Strengthen Your Position?
Partner with MHMDAA's physician-led team to build defensible, evidence-based processes that withstand scrutiny at every level.