CIMRO of Nebraska Beneficiary Protection/Case Review team reviews hospital requests for higher-weighted DRG (HWDRG) assignment referred to the QIO by CMS.  When reviewing hospital-requested higher-weighted DRG assignments, CIMRO of Nebraska nurses also perform a medical necessity/admission screening as well as a quality of care review if a potential quality of care concern is identified.

The purpose of DRG validation is to ensure that the diagnosis and procedures coded and reported by the hospital, match both the attending physician's description and the information contained in the beneficiary’s medical record. 

CIMRO of Nebraska’s Board of Directors has approved the adoption of the Milliman Care Guidelines® for all case review activities.  Beginning with care that was given on or after January 1, 2009, Case Review Nurses will use these guidelines to screen cases for medical necessity of admission. 

Charts are referred to physician review if clinical judgment is required for:

• A potential need to  change codes for a diagnosis and/or procedure not substantiated in the medical record
• To identify potential errors in the coding of the primary diagnosis or procedure. (Providers are notified when a confirmed review results in lower payment)
• A potential quality of care concern or
• Medical necessity/admission opinion

For additional resources, please visit the Documents and Links section.