Hospital Initiated Adjustment to Higher Weighted DRG

All claim adjustments submitted to Medicare that result in a higher DRG payment than the original claim are reviewed by AFMC to determine if the request for increased payment is supported by chart documentation. These adjustment requests must be made within 60 days of the first payment date. After the adjustment is submitted, AFMC will request information from the hospital medical records department. If all the required information is not received at AFMC within the time frame indicated on the request, Medicare will be notified to recoup the increased money paid. It is important that the billing office and the medical records department both be aware that an adjustment has been filed.

The following information will be requested by AFMC. Review will not be completed until all information is submitted.

• Copy of the entire medical record for indicated admission

• Original ICD-9-CM codes billed

• The ICD-9-CM codes submitted for adjustment

• A statement explaining why the original codes were submitted incorrectly

• Any new information that coding change was based on.