Payment integrity
Knowledge Center
Centene · payment integrity
Facility and inpatient
Inpatient DRG validation — complications and comorbidities
What a secondary diagnosis has to be supported by before it is allowed to raise the severity tier, and therefore the payment, of an admission.
Current version
v3.1
in force since 2026-01-01 · as at 2026-04-02
Versions on file
2
back to 2025-01-01
Applies to
Medicare Advantage · Medicaid
All states
Cited in this batch
8
claims tested against it
Where this sits
OwnerFacility Audit Policy
Lines of businessMedicare Advantage · Medicaid
StatesAll states
External basisCMS MS-DRG Definitions Manual v43 · ICD-10-CM Official Guidelines for Coding and Reporting
Version history
v3.1
2026-01-01 → current
In force now
Acute kidney injury reported as an MCC now requires creatinine values meeting a KDIGO stage against a documented baseline. Sepsis as an MCC requires documented organ dysfunction.
Extracted from
CPP-047_inpatient-drg-validation_v3.1.md
— 3 pages, indexed under
__live__,
so a finding on this version can quote it.
- A reported MCC or CC must be supported by clinical indicators, treatment, or monitoring in the record.
- Acute kidney injury requires creatinine meeting KDIGO stage 1 or above against a documented baseline.
- Where the MCC is not substantiated, the admission reprices to the DRG one severity tier down.
v3.0
2025-01-01 → 2025-12-31
Superseded
Baseline clinical-validation policy for the v42 grouper.
No source document in the index. A finding on this version can
cite it by name but cannot quote a passage.
- A reported MCC or CC must be supported by clinical indicators in the record.
- Where the MCC is not substantiated, the admission reprices one severity tier down.
Claims in this batch tested against this policy
| Claim | Date of service | Version applied | Role | Paid | At risk |
|---|---|---|---|---|---|
| CLM-0000015 | 09 Mar 2026 | v3.1 | Supporting | $7,532.36 | — |
| CLM-0000016 | 03 Mar 2026 | v3.1 | Supporting | $13,791.64 | — |
| CLM-0000017 | 14 Mar 2026 | v3.1 | Supporting | $5,504.60 | — |
| CLM-0000018 | 07 Mar 2026 | v3.1 | Supporting | $7,012.01 | — |
| CLM-0000019 | 21 Mar 2026 | v3.1 | Supporting | $7,920.05 | — |
| CLM-0000020 | 26 Mar 2026 | v3.1 | Supporting | $5,787.93 | — |
| CLM-0000013 | 12 Mar 2026 | v3.1 | Decisive | $8,729.84 | $2,956.64 |
| CLM-0000014 | 05 Mar 2026 | v3.1 | Supporting | $13,888.88 | $6,572.28 |
This policy is synthetic — an internal document written for this demo. The external basis it cites is real.