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Diagnosis Related Grouper (DRG) Validation Review Reimbursement Coding Policy
Blue Cross & Blue Shield of Mississippi·MS·Coding
Effective date
Nov 1, 2024
We identified it
Jun 20, 2026
Summary
Blue Cross Blue Shield Mississippi implemented a new DRG Validation Review policy that requires hospital claims with DRG codes to undergo comprehensive coding and clinical validation reviews. BCBSMS will review claims for coding accuracy, clinical documentation support, and may adjust DRG assignments and reimbursement rates based on medical record reviews.
Action Required
Immediately: Hospital billing teams must ensure all DRG-coded claims have complete and accurate documentation supporting diagnoses, procedures, and discharge status. Verify all secondary diagnoses meet clinical significance criteria (requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended stay, or increased nursing care). Ensure proper Present on Admission (POA) indicators for Hospital Acquired Conditions. Review coding practices for high-risk DRGs including sepsis, chronic conditions, and C-sections/vaginal deliveries. Claims may be subject to post-payment review and reimbursement adjustments.