Higher-Weighted Diagnosis-Related Group (DRG) Assignments

When a facility has determined that the DRG originally assigned did not appropriately reflect the services provided a Higher-Weighted DRG may be requested. These cases will be referred to NMMRA to validate the request.

NMMRA will request the medical record from the facility and review the record to ensure that the care provided was reasonable and medically necessary, was provided in the appropriate setting and met professional recognized standards. Review will also be performed to ensure that the principal diagnosis, all secondary diagnoses, all procedures affecting the DRG assignment, and the discharge status match both the attending physician's descriptions and the information contained in the patient's medical record and have been reported correctly on the claim. A Higher-Weighted DRG review of diagnoses and procedure coding will be conducted by an individual with training and experience in ICD-9-CM coding. If an issue requires a physician's medical judgment, the case will be referred to a physician peer reviewer of the affected practitioner before making a determination.