RCX | Payer Services

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DRG Denial / Appeal Management

RCX reviews claims for accuracy and integrity by ensuring clinical documentation support codes and DRG assigned and presented on payer claims.

RCX validates clinical documentation, coding and DRG assignment to ensure every diagnosis:

Meets established and best practice criteria
Is supported by clinical documentation in the record

We read the record, not just the claim.

Most payment integrity review stops at the claim: the codes, the DRG, the edits that fire against them. RCX opens the chart.

Our physicians, CDI nurses and certified DRG validators read the source documentation behind every impactful diagnosis and procedure, then confirm whether the DRG billed is the DRG the record actually supports. That difference is what separates a finding you can defend from a finding the provider overturns.

On every claim we review, RCX confirms that each impactful diagnosis and procedure:

Meets established clinical criteria and accepted definitions

Is supported by clinical documentation in the source medical record

Is coded and sequenced according to ICD-10-CM/PCS Official Guidelines and current Coding Clinic advice

Correctly drives the DRG assigned and paid on the claim

Four questions for your payment integrity team

Q. 01

How much of your inpatient spend is leaving on DRG assignments the medical record doesn't support?

Q. 02

When your current vendor's findings are appealed, how often do they hold?

Q. 03

Is your review reading the clinical documentation, or only the claim and the codes on it?

Q. 04

What is provider abrasion costing you in network relationships and rework?

For enquiries, contact us

RevCycle Xperts

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DRG Validation That Holds Up on Appeal