Section title: Requests for Interpretation
RFI #
2321
5010 835 CLP11
Description

When a provider submits a DRG (001-999) on our 837I claim, we are receiving back from several payers, a 4th digit. Our remit validator vendor code, is producing an error on each of these remits indicating "DRG Code is not a valid code". We contacted payers sending the 4 digit code and they indicated the 4th digit was the severity of illness. The 5010 IG reflects that 4 digits are acceptable (see IG, page #128). Is the 4th digit for expanded DRG's OR for the ability to send the severity of illness value? This response will provide us with a direction to either contact our validator vendor to accept 4 digits (severity of illness value as the 4th digit) OR work with our payers to cease sending the 4th digit.

Response

CLP11 reports the adjudicated DRG code from code source 229, which may be different than what was reported on the claim. CLP11 supports up to 4 digits in the DRG, reporting adjudicated DRG values from code source 229.  Refer to RFI 2166 for reporting DRG values other than code source 229.

DOCUMENT ID
005010X221A1