Claim edit: Missing diagnosis-related group code

Stedi now rejects 837I institutional claims that include diagnosis-related group (DRG) information but no DRG code.

Diagnosis-related group codes

In institutional claims, a diagnosis-related group (DRG) code groups inpatient hospital stays into categories expected to consume similar resources. For example, DRG 470 covers inpatient hip or knee replacements without complications.

Payers use DRG codes to determine fixed reimbursement rates under DRG-based contracts with providers. Medicare inpatient hospital reimbursement is the most common use case, though Medicaid and some commercial plans use different DRG systems.

DRG codes are only required if the provider's payer contract uses DRG reimbursement.

Diagnosis-related group (DRG) code

How the edit works

If you submit claims as raw X12, the DRG code goes in a DRG information segment: an HI segment in Loop 2300 (Claim Information) with DR in HI01-01. When that segment is present, X12 standards require a DRG code in HI01-02.

If you submit a claim that includes a DRG information segment without a DRG code, the payer may reject the claim.

This edit catches the issue before the claim reaches the payer. It prevents payer rejections, which take longer to resolve and delay payment for the provider.

Triggering the edit using the JSON API

If you use Stedi's JSON Institutional Claim Submission API endpoint, you can only trigger this edit by submitting a diagnosisRelatedGroupInformation object with an empty drugRelatedGroupCode string.

Rejection errors

If you submit a claim using Stedi's Claim Submission API endpoints and the claim fails the edit, you'll get back an error response in real time. The response includes details in the errors array:

{
  "errors": [
    {
      "code": "33",
      "description": "Missing Diagnosis Related Group (DRG) code. When the Diagnosis Related Group Information is present, then the specific DRG code must also be populated. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

If you submit a claim using SFTP and the claim fails the edit, Stedi will reject the claim with a 277CA claim acknowledgment. The acknowledgment will include a related claim status category code, claim status code, and error message:

STC*A6>256*[DATE]*U*[AMOUNT]********Missing Diagnosis Related Group (DRG) code. When the Diagnosis Related Group Information is present, then the specific DRG code must also be populated. Correct and resubmit.~

Related claim edits

Stedi has another edit for DRG code format. See Invalid diagnosis-related group code format.