MS-DRG 193: Simple Pneumonia and Pleurisy with MCC
CAP + MCC
Typical indications
- Pneumonia + sepsis
- Pneumonia + respiratory failure
Common denial patterns
- MCC validation
- Pneumonia diagnosis (sepsis vs not)
Appeal angles
Document CURB-65 ≥2, PSI ≥III, hypoxia, sepsis criteria meeting MCC.
Context: how MS-DRGs work
MS-DRGs bundle hospital inpatient payment into a single amount per admission. Each DRG has a relative weight that multiplies the hospital's base rate to determine payment. 193 has relative weight 1.4234. Major Complication or Comorbidity (MCC) and Complication or Comorbidity (CC) secondary diagnoses can move a case to a higher-paying DRG within the same family.
Frequently asked questions
What is MS-DRG 193?
Simple Pneumonia and Pleurisy with MCC. CAP + MCC.
What are typical indications?
Pneumonia + sepsis; Pneumonia + respiratory failure.
Why are claims under this DRG denied?
MCC validation; Pneumonia diagnosis (sepsis vs not).
How do I appeal?
Document CURB-65 ≥2, PSI ≥III, hypoxia, sepsis criteria meeting MCC.
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