Re: Pre-payment clinical validation review finding — MS-DRG 871 reassigned to MS-DRG 690
Anthem Blue Cross has completed a clinical validation review of the above-referenced inpatient admission under the Anthem Clinical Validation / DRG Payment Integrity Program and the terms of your facility's Participating Hospital Agreement. A credentialed clinical validation reviewer (RN, CCDS) compared the submitted UB-04 claim and coding summary against the medical record. Based on this review, the billed MS-DRG 871 is not supported by the clinical documentation, and this claim has been adjudicated and paid at the reassigned MS-DRG 690. This is a pre-payment determination; the claim was paid at MS-DRG 690. This notice constitutes Anthem's determination and explains your right to dispute it.
Based on review of the medical record against MCG Care Guidelines, 28th Edition, the clinical documentation does not support the secondary diagnoses that drive MS-DRG 871 — severe sepsis with septic shock (R65.21) and acute kidney failure (N17.9). This claim has been reassigned to MS-DRG 690 (Kidney & urinary tract infections w/o MCC) under the Anthem Clinical Validation / DRG Payment Integrity Program.
Based on the review above, Anthem Blue Cross has reassigned this claim from MS-DRG 871 to MS-DRG 690. This is a pre-payment determination; the claim was paid at MS-DRG 690. The reassigned amounts are itemized below.
| Item | Value |
|---|---|
| Billed MS-DRG | 871 — Septicemia or severe sepsis w/o MV 96+ hours w/ MCC (CMI 1.9048) |
| Reassigned MS-DRG | 690 — Kidney & urinary tract infections w/o MCC (CMI 0.8009) |
| Reassigned Principal Diagnosis | N10 — Acute pyelonephritis |
| Expected Payment at MS-DRG 871 | $33,420.00 |
| Paid at MS-DRG 690 | $14,050.00 |
| Amount in Dispute (DRG differential) | $19,370.00 |
| Adjustment Codes | CO-50 / N527 |
| Determination Type | Pre-payment DRG reassignment (no recoupment) |
| Effective Date | 05/11/2026 |
MCG Care Guidelines, 28th Edition — Inpatient & Surgical Care (Sepsis); Anthem Clinical Validation / DRG Payment Integrity Program Policy. This is an administrative payment-integrity determination regarding DRG severity assignment and is not a determination that the inpatient admission itself was non-covered.
You have the right to dispute this determination through Anthem's provider dispute resolution process, consistent with the California provider dispute resolution requirements and your Participating Hospital Agreement. A written provider dispute with supporting documentation must be received within 180 calendar days, by 11/07/2026, via the Anthem Availity provider portal, by fax to (818) 234-3589, or by mail to: Anthem Blue Cross — Grievance & Appeals Dept, P.O. Box 4310, Woodland Hills, CA 91365. Anthem will issue a written determination within forty-five (45) working days of receipt of a complete provider dispute.
Anthem Blue Cross complies with applicable Federal and California civil rights laws and does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability. If you believe Anthem Blue Cross has failed to provide these services or discriminated in another way, you may file a grievance with the Anthem Blue Cross Grievance & Appeals Department.
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[Source: Anthem Clinical Validation / DRG Payment Integrity Program Policy; MCG Care Guidelines, 28th Edition — Inpatient & Surgical Care]