Section title: Requests for Interpretation
835 MS-DRG Reporting, CLP11

Our health plan has negotiated multiyear contracts with hospitals that specify which MS-DRG version must be used for claims reimbursement. At this time, we populate the CLP11 data element with the MS-DRG code value that is used in the adjudication process. When the MS-DRG code value in the CLP11 is from a prior version of the MS-DRG code set, and based on the contract, validation software will produce an error that indicates the DRG code is invalid. This error occurs because the MS-DRG code value in the CLP11 is not from the current MS-DRG version of code source 229.

Can the 2100 REF*CE be used, rather than the CLP11 data element when reporting a code from the previous version of the MS-DRG? If not, is there another location within the 835 transaction that supports reporting a previous version of the MS-DRG when it is used for adjudication and is based on a hospital/health plan contract?

RFI Response

No, the REF*CE must not be used to report MS-DRG (Code source 229). The MS-DRG is situationally required to be reported in CLP11 per the 005010A1 835 TR3

RFI Recommendation

in this specific situation when there is a business arrangement and/or contract between the payer and a provider (i.e. two trading partners) to use an older version of the MS-DRG code set, the trading partners can make a business decision to have their validators turn off the edit on CLP11 for that specific business arrangement between those two trading partners.