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December 23, 2025

TPE: Inpatient Hospital Services

Current Targeted Probe and Educate (TPE) Medicare Severity Diagnosis Related Groups (MS-DRG) reviews for inpatient hospital services include:

Inpatient Psychiatric Admissions (DRG 885: Psychoses)
Kidney and Urinary Tract Infections (UTI) with & without Major Complication and Comorbidity (MCC) (DRGs 689 & 690)
Heart Failure and Shock with Major Complication and Comorbidity (MCC) (DRG 291)

MS-DRG Coding requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate MS-DRGs for principal and secondary diagnosis and procedures affecting or potentially affecting the MS-DRG assignment.

Key Actions to Avoid Denials

Ensure your facility has internal processes in place to monitor Additional Documentation Requests (ADRs) and respond promptly.
- Claims will deny (reason code 56900) if the requested medical records aren't received within 45 calendar days.
Submit all pertinent documentation that clearly supports the DRG assigned.

Documentation Submission Tips

Collaborate with clinical staff to ensure the medical record submission contains all required elements to support the services billed.
- myCGS® portal (preferred submission method)
Page 1: Include a copy of the ADR letter.
Page 2: Include the TPE ADR cover sheet that identifies 1-2 designated provider contacts (preferably a clinical contact familiar with the review). This allows CGS to successfully complete any educational outreach attempts or calls to request missing records.
- If a designated provider contact is missing or we don't receive a prompt return call, you may miss an opportunity to prevent a claim denial.

Common Denials: Inpatient Psychiatric Admissions (DRG 885: Psychoses)

Documentation submitted is missing:
- Physician certification for the inpatient psychiatric services or a delayed certification with a reason for the delay.
- Psychiatric evaluation completed within 60 hours of admission.
- Individualized comprehensive treatment plan.

Common Denials: Kidney and UTI with & without MCC (DRGs 689 & 690)

Principal diagnosis for the inpatient admission isn't related to kidney/UTI.
Documentation submitted doesn't support the MCC billed.
- The MCC must represent a significant increase in the intensity of services provided or the use of additional resources during the stay supporting the severity of the beneficiary's condition.

Common Denials: Heart Failure and Shock with MCC (DRG 291)

Principal diagnosis for the inpatient admission isn't related to heart failure.
Documentation submitted doesn't support the MCC billed.
- The MCC must represent a significant increase in the intensity of services provided or the use of additional resources during the stay supporting the severity of the beneficiary's condition.
Secondary diagnosis and/or MCC billed are related to the principal diagnosis.
- Claims may deny if the secondary diagnosis and/or MCC diagnosis is the same or similar to the principal diagnosis billed on the claim.

Resources

If you have questions, please email: J15AMREDUCATION@cgsadmin.com.

To help us expedite our response, please include the facility name, National Provider Identifier (NPI) or Provider Transaction Access Number (PTAN), and the specific review related to your inquiry.

Please don't include PHI/PII. If your question is about a specific claim, please reference the Document Control Number (DCN) only.