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Back  RFI # 411: DRG Weight Requirement

Formal vs. Informal Help Informal Formal

Submitter

Bob Resh

Description

A payer has delivered 835s where specific claims report a DRG in CLP11 but do not contain anything in CLP12. When questioned, the payer states that they do not use DRG Weight. As we read the guide, DRG Wieght is required when a DRG is involved in a claim adjudication, not just when the DRG Weight applies. Who is correct, and what value should a payer in this situation be sending if they must send a DRG weight?

Submitter Assigned Keywords

DRG Weight

Response

The note on CLP12 reads “This data element is specific to institutional claims and is required when adjudication considers the DRG.” If CLP11 (DRG) is populated, this means that adjudication considered the DRG, therefore CLP12 is required when CLP11 is present. If the Payer does not consider the DRG Weight in their adjudication, a default value of “1” should be used in CLP12 when CLP11 is present.
Submission 5/26/2006
Status Date 7/24/2006
Status F - Final
Primary References
Document 004010X091A1
Section3
Page93
Set ID835
Table2
Loop2100
Segment Position010
Segment IDCLP
Element Position12
Industry NameDiagnosis Related Group (DRG) Weight