Post Payment Diagnosis Related Group Review of Inpatient Medicaid Services
North Carolina Medicaid reimburses most hospitals for inpatient services using a Diagnostic Related Grouping (DRG) payment methodology. CCME conducts post payment review on approximately 446 medical records each month. DRG validation is performed to ascertain that the diagnostic and procedural information that led to the DRG assignment is substantiated by the medical record. In addition, the medical necessity of inpatient acute care admissions is determined based on documentation in the medical record using established, recognized criteria. CCME routinely monitors DRG billing patterns and the review process on an ongoing basis. CCME makes recommendations for change to DMA when patterns are identified

Currently targeted for review are the following selections:

• DRG 981,982,983 (Extensive OR Procedure Unrelated to Principal Diagnosis)
• DRG 790 (Extreme Immaturity or Respiratory Distress Syndrome, Neonate)
• DRG 791 (Prematurity with major Problems, Neonate)
• DRG 793 (Full Term Neonate with Major Problems)
• V22.2 (Pregnant state, incidental)
• Readmissions
• Short-Stay hospitalizations

For questions or additional information about the review process, contact Leslie Meilhon at 919-380-9860, ext. 2026, or lmeilhon@thecarolinascenter.org.