Part 7: Most Common DRG’s with Recommendations – DRG 682

This is the next most common DRG with recommendations found in HIA reviews in 2021. Just to recap, HIA reviewed almost 50,000 inpatient records and over a half a million codes in 2021. We will look at the top DRG’s with recommendations and see what can be done to prevent DRG changes going forward. Each coding tidbit will contain some tips for coding within the DRG or diagnosis area. 


#7: DRG 682—Renal failure with MCC

DRG 682 (Renal failure with MCC) was the number 7 most common DRG with recommendations from HIA in 2021.

Records reviewed: 339
DRG recommended changes: 75
Accuracy of DRG 682: 77.88%


Renal failure can either be a chronic or acute condition. Acute renal failure has been on a steady incline at around 14% per year. Some researchers felt this could be due to misunderstanding of the diagnosis. 

When the kidneys are suddenly unable to filter waste products from your blood is considered acute renal failure or injury. This usually develops very quickly and is more prevalent in patients that are already hospitalized. This condition may be reversible.

When the kidneys are losing function gradually, this is considered chronic renal disease/failure. This type is not reversible, but can be slowed down with treatment at the underlying cause. Most patients do not realize that they have CKD until it is advanced. There are around 15% or 37 million adult patients in America with CKD. This number is felt to be low since this does not include the adults that do not know they have this disease.


Reasons for DRG 682 recommendations:

The majority of the recommendation from DRG 682 (Renal failure with MCC) were due to PDX (very few required physician query) and revision or deletion of reported MCC (only a couple required physician query). Out of the total 74 DRG recommendations made, only 16 required a query.

  • The most common reason for DRG recommendations was to re-sequence or add a new PDX. Only a few of these required a physician query for clarification. There was no trend to the recommended DRGs, but the DRG 640 (Miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with MCC) did have the most recommendations (12). What this means is that there was sufficient documentation in the medical record to support the new PDX. Remember, when coding, if there is more than one condition responsible for the admission, treatment of one of the conditions may be more resourceful, or one of the conditions was focused on. When this happens, the conditions are no longer considered “equal.” In cases where there is two or more potential PDX, a coder should select for the PDX, the condition that required the most resources. Each record must be reviewed independently as no across the board statement would be applicable here. It will all depend on the focus of treatment once the patient is admitted for multiple conditions.
  • The next most common reason for changes was to delete or clarify the reported MCC. There were several records that the MCC was not clearly documented or supported. A little of ¼ of these did require a query to clarify the MCC. The others were recommended with the documentation available at the time of original coding.

What can coders do to improve the accuracy of reporting DRG 682?

The most important thing that a coder can do is to make sure that there are no questions that could be raised regarding any diagnosis or procedure that is used to calculate the DRG. Ask yourself these questions when coding:

  • Verify the reasons for the patient’s admission. When multiple conditions necessitate the admission, and equally meet the criteria for principal diagnosis, any of these may be sequenced first. The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
  • Validate all MCC’s to ensure that documentation is in the medical record to support that these conditions should be reported. If there’s a chance that the condition may be ruled out, a query should be sent for clarification. When only 1 MCC is present on a record it is always best practice to double check to ensure that the condition meets reporting requirements as well as clinical validity so that it is protected in any audits.
  • If there is a question about a diagnosis or procedure in the record that does impact the DRG, a query should be sent or coders should follow the procedure for their facility to escalate the record to a senior reviewer or physician liaison.
  • Query anytime there is ambiguous of conflicted documentation prior to coding finalization
  • Bottom line is to protect the DRG at final coding by making sure that it is correct, and that there will be no question after final billing about the ICD-10-CM and/or ICD-10-PCS codes that were reported.

Coders should review the entire medical record to look for any conflicting documentation and clarify this prior to final coding. Clarification prior to final coding will decrease audit recommendations and denials. Remember, denials are costly to the facility with all the time that is spent trying to appeal.


Please visit HIA’s blog for additional information/articles on reporting renal failure at:



ICD-10-CM Official Guidelines for Coding and Reporting FY 2022
ICD-10-PCS Official Guidelines for Coding and Reporting FY 2022

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

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