HWDRG Reviews

Hospitals may submit requests for higher-weighted diagnosis-related group (HWDRG) assignments directly to their Medicare fiscal intermediary for processing and payment. All such requests granted by the intermediary for Idaho and Washington hospitals are subsequently sent to Qualis Health to review on a post-payment basis.

As specified in 42 CFR §412.60(d)(2) and 42 CFR §476.71, QIOs review hospital-requested HWDRG assignments for medical necessity, DRG validation, and quality.

• The purpose of DRG validation review is to ensure that the diagnostic, procedural, and discharge coding matches both the attending physician’s description and the information contained in the patient’s medical record. Any resulting payment adjustments will be completed by the intermediary automatically, without requiring the hospital to submit a revised bill.
• If a concern is identified, Qualis Health will initiate a quality-of-care review.