Checklist: Diagnostic-Related Group (DRG) Validation
This checklist is intended to provide Health care providers with a reference to use when responding to medical documentation requests for DRG validation services. Health care providers retain responsibility to submit complete and accurate documentation.
| Check |
Documentation description |
|---|---|
| Documentation is legible |
|
| Documentation is for the correct beneficiary |
|
| Documentation is for the correct date(s) of service |
|
| Documentation contains valid signatures |
|
| Admission and discharge summary |
|
| Physician orders |
|
| History and physical including physician, nurse, dietician and other multi-disciplinary |
|
| All progress notes including physician, nurse, dietician and other multi-disciplines |
|
| All test results including lab results to support admission |
|
| Therapy treatment logs and treatment notes |
|
| Infusion therapy flow sheets |
|
| Medication logs |
|
| Emergency room records |
|
| Operative / procedure reports |
|
| Consult reports |
|
| Discharge assessment / plan |
|
| Documentation to support all services billed |
|
| Itemized Bill |
Disclaimer
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS’ documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.