DCS approved audit issues
Updated as of 03/28/2011
Issue Name:
MS-DRG Validation: MDC 19-Mental Diseases And Disorders MS-DRGs:
876, 880, 881, 882, 883, 884, 885, 886, and 887 (Medical Necessity
Excluded)
Issue
Number
A000612011
Issue
Description:
MS-DRG validation requires that diagnostic and procedural information and
the discharge status of the beneficiary, as coded by the hospital on its claim,
matches both the attending physician description and the information
contained in the medical record. Reviewers will validate MS-DRGs 876, 880,
881, 882, 883, 884, 885, 886 and 887 for principal and secondary diagnoses
and procedures affecting or potentially affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Providers
Affected:
Inpatient Hospital
Date Posted: March 25, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99); PIM,
Chapter 6.5.3 DRG Validation Review; Uniform Hospital Discharge Data Set
(UHDDS) Reporting of Inpatient Data Elements, July 31, 1985; Federal
Register (Vol.50, No. 147) Pages 31038-31040;
Issue Name:
MS-DRG Validation: MDC 20-Alcohol/Drug Use And Alcohol/Drug-Induced
Organic Mental Disorders MS-DRG 894, 895, 896 and 897 (Medical
Necessity Excluded)
Issue
Number
A000622011
Issue
Description:
MS-DRG validation 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 894, 895, 896 and 897 for principal and secondary
diagnoses and procedures affecting or potentially affecting the MS-DRG
assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT. PA, DE, DC, RI, CT, NJ: excluding Maryland (MD)
Providers
Affected:
Inpatient Hospital
Date Posted: March 25, 2011
Dates of
Rolling 36 month review look back
Service:
Issue
References
Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99); PIM,
Chapter 6.5.3 DRG Validation Review; Uniform Hospital Discharge Data Set
(UHDDS) Reporting of Inpatient Data Elements, July 31, 1985; Federal
Register (Vol.50, No. 147) Pages 31038-31040;
Issue Name:
MS-DRG Validation: Burns MS-DRGs 928, 929, 934 and 935 (Medical
Necessity Excluded)
Issue
Number
A000632011
Issue
Description:
MS-DRG validation requires that diagnostic and procedural information and
the discharge status of the beneficiary, as coded by the hospital on its claim,
matches both the attending physician description and the information
contained in the medical record. Reviewers will validate MS-DRGs 928, 929,
934 and 935 for principal and secondary diagnoses and procedures affecting
or potentially affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ: excluding Maryland (MD)
Providers
Affected:
Inpatient Hospital
Date Posted: March 25, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99); PIM,
Chapter 6.5.3 DRG Validation Review; Uniform Hospital Discharge Data Set
(UHDDS) Reporting of Inpatient Data Elements, July 31, 1985; Federal
Register (Vol.50, No. 147) Pages 31038-31040;
Issue Name:
MS-DRG Validation: MDC 23-Factors Influencing Health Status & Other
Contacts with Health Services MS-DRGs 939, 940, 941, 945, 946, 947, 948,
949, 950 and 951 (Medical Necessity Excluded)
Issue
Number
A000642011
Issue
Description:
MS-DRG validation requires that diagnostic and procedural information and
the discharge status of the beneficiary, as coded by the hospital on its claim,
matches both the attending physician description and the information
contained in the medical record. Reviewers will validate MS-DRGs 939, 940,
941, 945, 946, 947, 948, 949, 950 and 951 for principal and secondary
diagnoses and procedures affecting or potentially affecting the MS-DRG
assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Providers
Affected:
Inpatient Hospital
Date Posted: March 25, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99); PIM,
Chapter 6.5.3 DRG Validation Review; Uniform Hospital Discharge Data Set
(UHDDS) Reporting of Inpatient Data Elements, July 31, 1985; Federal
Register (Vol.50, No. 147) Pages 31038-31040;
Issue Name:
MS-DRG Validation: MDC-24 Multiple Significant Trauma MS-DRGs 955,
956, 957, 958, 959, 963, 964 and 965 (Medical Necessity Excluded)
Issue
Number
A000652011
Issue
Description:
MS-DRG validation requires that diagnostic and procedural information and
the discharge status of the beneficiary, as coded by the hospital on its claim,
matches both the attending physician description and the information
contained in the medical record. Reviewers will validate MS-DRGs 955, 956,
957, 958, 959, 963, 964 and 965 for principal and secondary diagnoses and
procedures affecting or potentially affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Providers
Affected:
Inpatient Hospital
Date Posted: March 25, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99); PIM,
Chapter 6.5.3 DRG Validation Review; Uniform Hospital Discharge Data Set
(UHDDS) Reporting of Inpatient Data Elements, July 31, 1985; Federal
Register (Vol.50, No. 147) Pages 31038-31040;
Issue Name:
MS-DRG Validation: MDC 25-Human Immunodeficiency Virus Infections
MSDRGs 969, 970, 974, 975, 976 and 977. (Medical Necessity Excluded)
Issue
Number
A000662011
Issue
Description:
MS-DRG validation requires that diagnostic and procedural information and
the discharge status of the beneficiary, as coded by the hospital on its claim,
matches both the attending physician description and the information
contained in the medical record. Reviewers will validate MSDRGs 969, 970,
974, 975, 976 and 977 for principal and secondary diagnoses and
procedures affecting or potentially affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Providers
Affected:
Inpatient Hospital
Date Posted: March 25, 2011
Dates of
Rolling 36 month review look back
Service:
Issue
References
Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99); PIM,
Chapter 6.5.3 DRG Validation Review; Uniform Hospital Discharge Data Set
(UHDDS) Reporting of Inpatient Data Elements, July 31, 1985; Federal
Register (Vol.50, No. 147) Pages 31038-31040;
Issue Name:
MS-DRG Validation: DRGs Associated with All MDCs MS-DRGs 984, 985,
986, 998 and 999 (Medical Necessity Excluded)
Issue
Number
A000672011
Issue
Description:
MS-DRG validation requires that diagnostic and procedural information and
the discharge status of the beneficiary, as coded by the hospital on its claim,
matches both the attending physician description and the information
contained in the medical record. Reviewers will validate MS-DRGs 984, 985,
986, 987, 998 and 999 for principal and secondary diagnoses and
procedures affecting or potentially affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE. DC. RI. CT. NJ: excluding Maryland (MD)
Providers
Affected:
Inpatient Hospital
Date Posted: March 25, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99); PIM,
Chapter 6.5.3 DRG Validation Review; Uniform Hospital Discharge Data Set
(UHDDS) Reporting of Inpatient Data Elements, July 31, 1985; Federal
Register (Vol.50, No. 147) Pages 31038-31040;
Issue Name: Medical Necessity Review (MNR) for MS-DRG 101 Seizures without MCC
Issue
Number
A000352011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This will be of MS-DRG 101 Seizures
without MCC
Type of
Review
Medical Necessity Review
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ: excluding MD
Providers
Affected:
Inpatient Hospital
Date Posted: March 3, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Issue Name: Medical Necessity Review (MNR) for MS-DRG 102 Headaches with MCC
Issue
Number
A000372011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This review will be of MS-DRG 102
Headaches with MCC.
Type of
Review
Medical Necessity Review
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ: excluding MD
Providers
Affected:
Inpatient Hospital
Date Posted: March 3, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Issue Name:
Medical Necessity Review (MNR) for MS-DRG 114 Orbital Procedures
without CC/MCC
Issue
Number
A000382011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This review will be for MS-DRG 114
Orbital Procedures without CC/MCC.
Type of
Medical Necessity Review
Review
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ: excluding MD
Providers
Affected:
Inpatient Hospital
Date Posted: March 3, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Issue Name: Medical Necessity Review (MNR) for MS-DRG 150 Epistaxis with MCC
Issue
Number
A000392011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This review will be for MS-DRG 150
Epistaxis with MCC.
Type of
Review
Medical Necessity Review
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ: excluding MD
Providers
Affected:
Inpatient Hospital
Date Posted: March 3, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Issue Name: Medical Necessity Review (MNR) for MS-DRG 151 Epistaxis without MCC
Issue
Number
A000402011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This review will be of MS-DRG 151
Epistaxis without MCC.
Type of
Review
Medical Necessity Review
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ: excluding MD
Providers
Affected:
Inpatient Hospital
Date Posted: March 3, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Issue Name:
Medical Necessity Review (MNR) for MS-DRG 154 Other Ear, Nose, Mouth,
& Throat Diagnoses with MCC
Issue
Number
A000412011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This review will be of MS-DRG 154
Other Ear, Nose, Mouth, & Throat Diagnoses with MCC.
Type of
Review
Medical Necessity Review
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ: excluding MD
Providers
Affected:
Inpatient Hospital
Date Posted: March 3, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Issue Name:
Medical Necessity Review (MNR) for MS-DRG 156 Other Ear, Nose, Mouth
& Throat Diagnoses without CC/MCC.
Issue
Number
A000422011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This review will be of MS-DRG 156
Other Ear, Nose, Mouth & Throat Diagnoses without CC/MCC
Type of
Review
Medical Necessity Review
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ: excluding MD
Providers
Affected:
Inpatient Hospital
Date Posted: March 3, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Issue Name:
Medical Necessity Review (MNR) for MS-DRG 505 Foot Procedures without
CC/MCC
Issue
Number
A000432011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This review will be of MS-DRG 505 Foot
Procedures without CC/MCC.
Type of
Review
Medical Necessity Review
State(s)
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ: excluding MD
Affected:
Providers
Affected:
Inpatient Hospital
Date Posted: March 3, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Issue Name:
Medical Necessity Review (MNR) for MS-DRG 090 Concussion without
CC/MCC
Issue
Number
A000342011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This review will be of MS-DRG 090
Concussion without CC/MCC
Type of
Review
Medical Necessity Review
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ: excluding MD
Providers
Affected:
Inpatient Hospital
Date Posted: March 2, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
Program Integrity Manual (PIM) Chapter 6.5.2;; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10;; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Issue Name:
Acute Inpatient Hospitalization - Musculoskeletal Disorders MS-DRGs: 542566
Issue
Number
A000152011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary
for the setting billed. Medical documentation will be reviewed to determine
that services were medically necessary. MS-DRG: 542-566
Type of
Review
Medical Necessity Review
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ: excluding MD.
Providers
Affected:
Inpatient Hospital
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
CMS Publication 100-02 Medicare Claims Processing Manual:Chapter 1 §
10; CMS Publication 100-02 Medicare Claims Processing Manual:Chapter 6
§ 10; CMS Publication 100-02 Medicare Claims Processing Manual:Chapter
6 § 6.5.2; CMS Publication 100-02 Medicare Claims Processing
Manual:Chapter 13 § 13.1; 13.1.1;
Issue Name:
Medical Necessity Review: Other Disorders of the Eye without MCC MSDRG 125
Issue
Number
A000182011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This review will be of MS-DRG 125Other Disorders of the Eye without MCC
Type of
Review
Medical Necessity Reviews
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ: excluding MD.
Providers
Affected:
Inpatient Hospitals
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21),; Medicare
Program Integrity Manual (PIM) Chapter 6.5.2;; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10;; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Issue Name:
Acute Inpatient Hospitalization - Infections MS-DRG: 094-096;177-179;488489;539-41;602-603;689-690;856-858;862-9;871-872;977
Issue
Number
A000162011
Medicare pays for inpatient hospital services that are medically necessary for
Issue
the setting billed. Medical documentation will be reviewed to determine that
Description: services were medically necessary. MS-DRG: 094-096;177-179;488489;539-41;602-603;689-690;856-858;862-9;871-872;977”
Type of
Review
Medical Necessity Review
State(s)
Affected:
NY, NH, MA,ME,VT,PA,DE,DC,RI,CT,NJ;excluding MD
Providers
Affected:
Inpatient Hospitals
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
CMS Publication 100-02 Medicare Claims Processing Manual: Chapter 1 §
10; CMS Publication 100-02 Medicare Claims Processing Manual:Chapter 6
§ 10; CMS Publication 100-08 Medicare Program Integrity Manual:Chapter 6
§ 6.5.2; CMS Publication 100-08 Medicare Program Integrity Manual:Chapter
13 § 13.1; 13.1.1;
Issue Name: Medical Necessity Review: Disorders of the Eye with MCC MS-DRG 124
Issue
Number
A000172011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This review will be of MS-DRG 124
Disorders of the Eye with MCC
Type of
Review
Medical Necessity Review
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ: excluding MD.
Providers
Affected:
Inpatient Hospitals
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21),; Medicare
Program Integrity Manual (PIM) Chapter 6.5.2;; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10;; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Issue Name: Medical Necessity Review: Otitis Media & URI without MCC MS-DRG 153
Issue
Number
A000202011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This will be of MS-DRG 153-Otitis Media
& URI without MCC
Type of
Review
Medical Necessity Review
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ: excluding MD.
Providers
Affected:
Inpatient Hospital
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21; Medicare
Program Integrity Manual (PIM) Chapter 6.5.2;; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10;; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Issue Name:
Medical Necessity Review: Trauma to the Skin, Subcutaneous Tissue &
Breast without MCC MS-DRG 605
Issue
Number
A000212011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This review will be of MS-DRG 605
Trauma to the Skin, Subcutaneous Tissue & Breast without MCC.
Type of
Review
Medical Necessity Review
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ: excluding MD.
Providers
Affected:
Inpatient Hospitals
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21),; Medicare
Program Integrity Manual (PIM) Chapter 6.5.2;; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10;; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Issue Name:
Medical Necessity Review : Mouth Procedures without CC/MCC MS-DRG
138
Issue
Number
A000192011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This review will be of MS-DRG 138
Mouth Procedures without CC/MCC
Type of
Review
Medical Necessity Review
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ: excluding MD
Providers
Affected:
Inpatient Hospital
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21),; Medicare
Program Integrity Manual (PIM) Chapter 6.5.2;; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10;; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Issue Name:
MS-DRG Validation: Transplants MS-DRGs 001, 005, 007, 008, 009 and 010
(Medical Necessity Excluded)
Issue
Number
A000222011
Issue
Description:
MS-DRG Validation 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 001, 005, 007, 008, 009, and 010 for principal and
secondary diagnoses and procedures affecting or potentially affecting the
MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; exclude Maryland (MD)
Providers
Affected:
Inpatient Hospital
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG Report OAI-12-88-01010. ICD-9-CM Coding Manual (for dates of
service on claim); PIM 6.5.3 A-C DRG Validation Review; Uniform Hospital
Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31,
1985, Federal Register (Vol. 50, No. 147), Pages 31038-31040;
Issue Name:
MS-DRG Validation: Respiratory Infections and Inflammations: MS-DRG 178
(Medical Necessity Excluded)
Issue
Number
A000232011
Issue
Description:
MS-DRG Validation 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-DRG 178 for principal and secondary diagnoses and procedures
affecting or potentially affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; exclude Maryland (MD)
Providers
Affected:
Inpatient Hospitals
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review;
Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 3103831040;
Issue Name:
MS-DRG Validation: Biliary Tract, Heptobiliary and Pancreas Procedures:
MS-DRGs: 408, 409, 410, 420, 421, 422, 423, 424 and 425 (Medical
Necessity Excluded)
Issue
A000242011
Number
Issue
Description:
MS-DRG Validation 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 408, 409, 410, 420, 421, 422, 423, 424 and 425 for
principal and secondary diagnoses and procedures affecting or potentially
affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; exclude Maryland (MD)
Providers
Affected:
Inpatient Hospitals
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review,;
Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 3103831040;
Issue Name:
MS-DRG Validation: Aftercare, musculoskeletal system & connective tissue
MS-DRGs: 559, 560 and 561 (Medical Necessity Excluded)
Issue
Number
A000252011
Issue
Description:
MS-DRG Validation 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 559, 560 and 561 for principal and secondary diagnoses
and procedures affecting or potentially affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; exclude Maryland (MD)
Providers
Affected:
Inpatient Hospital
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review;
Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 3103831040;
Issue Name:
MS-DRG Validation: Breast Disorders. MS-DRGs 597, 598, 599, 600 and
601. (Medical Necessity Excluded)
Issue
A000312011
Number
Issue
Description:
MS-DRG Validation 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 597, 598, 599, 600 and 601 for principal and secondary
diagnoses and procedures affecting or potentially affecting the MS-DRG
assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; exclude Maryland (MD)
Providers
Affected:
Inpatient Hospitals
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review,;
Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 3103831040;
Issue Name:
MS-DRG Validation: Skin Disorders: MS-DRGs 593, 594, 595, 596, 603,
604, 605, 606 and 607 (Medical Necessity Excluded)
Issue
Number
A000262011
Issue
Description:
MS-DRG Validation 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 593, 594, 595, 596, 603, 604, 605, 606 and 607 for
principal and secondary diagnoses and procedures affecting or potentially
affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; exclude Maryland (MD)
Providers
Affected:
Inpatient Hospitals
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review;
Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 3103831040;
Issue Name:
MS-DRG Validation: Breast Procedures. MS-DRGs 582, 583, 584 and 585.
(Medical Necessity Excluded)
Issue
Number
A000322011
Issue
Description:
MS-DRG Validation 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 582, 583, 584, and 585 for principal and secondary
diagnoses and procedures affecting or potentially affecting the MS-DRG
assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; exclude Maryland (MD)
Providers
Affected:
Inpatient Hospitals
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review,;
Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 3103831040;
Issue Name:
MS-DRG Validation: Kidney Transplant-Urinary Stones: MS-DRGs 652, 692
and 694 (Medical Necessity Excluded)
Issue
Number
A000272011
Issue
Description:
MS-DRG Validation 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 652, 692 and 694 for principal and secondary diagnoses
and procedures affecting or potentially affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; exclude Maryland (MD)
Providers
Affected:
Inpatient Hospitals
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review,;
Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 3103831040;
Issue Name:
MS-DRG Validation: Male Reproductive System Procedures: MS-DRGs 707,
708, 709, 710, 711, 712, 713, 714, 715, 716, 717 and 718 (Medical
Necessity Excluded)
Issue
Number
A000282011
Issue
Description:
MS-DRG Validation 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 707, 708, 709, 710, 711, 712, 713, 714, 715, 716, 717
and 718 for principal and secondary diagnoses and procedures affecting or
potentially affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; exclude Maryland (MD)
Providers
Affected:
Inpatient Hospitals
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review,;
Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 3103831040;
Issue Name:
MS-DRG Validation: Male Reproductive System Disorders MS-DRGs 722,
723, 724, 725, 726, 727, 728. 729 and 730 (Medical Necessity Excluded)
Issue
Number
A000332011
Issue
Description:
MS-DRG Validation 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 722, 723, 724, 725, 726, 727, 728. 729 and 730 for
principal and secondary diagnoses and procedures affecting or potentially
affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; exclude Maryland (MD)
Providers
Affected:
Inpatient Hospital
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review,;
Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 3103831040;
Issue Name:
MS-DRG Validation: Female Reproductive System Disorders: MS-DRGs
754, 755, 756, 757, 758, 759, 760 and 761 (Medical Necessity Excluded)
Issue
Number
A000292011
Issue
Description:
MS-DRG Validation 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 754, 755, 756, 757, 758, 759, 760 and 761 for principal
and secondary diagnoses and procedures affecting or potentially affecting
the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; exclude Maryland (MD)
Providers
Affected:
Inpatient Hospital
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review,;
Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 3103831040;
Issue Name:
MS-DRG Validation: Pregnancy, Childbirth & Puerperium: MS-DRGs 765,
766, 767, 768, 769, 770, 774, 775, 776, 777, 778, 779, 780, 781, and 782
(Medical Necessity Excluded)
Issue
Number
A000302011
Issue
Description:
MS-DRG Validation 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 765, 766, 767, 768, 769, 770, 774, 775, 776, 777, 778,
779, 780, 781, and 782 for principal and secondary diagnoses and
procedures affecting or potentially affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; exclude Maryland (MD)
Providers
Affected:
Inpatient Hospital
Date Posted: March 1, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review,;
Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 3103831040;
Medical Necessity: Acute Inpatient Admission Respiratory Conditions. The
Issue Name: MS DRGs affected are MS DRG 177-180, MS DRG 190-198 and MS DRG
202-206.
Issue
Number
A000022011
Issue
Description:
RACs will review documentation to validate the medical necessity of short
stay, uncomplicated admissions. Medicare only pays for inpatient hospital
services that are medically necessary for the setting billed and that are
coded correctly. Medical documentation will be reviewed to determine that
the services were medically necessary and were billed correctly. The MS
DRGs affected are MS DRG 177-180, MS DRG 190-198 and MS DRG 202206.
Type of
Review
Medical Necessity Review
State(s)
Affected:
PA, DC, NJ, DE, NY, CT, VT, ME, MA, NH, RI
Providers
Affected:
Inpatient Hospitals
Date Posted: February 24, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
RAC Demonstration Evaluation; Medicare Benefit Policy Manual Chapter 1 Inpatient Hospital Services Covered Under Part A; Medicare Benefit Policy
Manual Chapter 6 - Hospital Services Covered Under Part B; Medicare
Program Integrity Manual Chapter 6 - Intermediary MR Guidelines for
Specific Services; Medicare Program Integrity Manual Chapter 13 – Local
Coverage Determinations;
Issue Name: Incorrect Bilateral Billing for Codes with Bilateral Indicator 3
Issue
Number
A001312010
Overpayments associated with providers incorrectly billing services with
Issue
bilateral indicator 3 (100% payable for each side) on multiple lines; once with
Description: modifier 50 (resulting in 200% payment) and once without modifier 50
(resulting in 100% payment), resulting in a 300% total payment.
Type of
Review
Automated
State(s)
Affected:
DC, CT, DE, MD, NJ, NY, PA
Providers
Affected:
Professional Services
Date Posted: February 18, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
CMS Medicare Physician Fee Schedule 2007-2010, RVUPUF File, Bilateral
Indicator 3 Description. See Appendix E; CMS Internet Only Manual 100-04
(Medicare Claims Processing Manual), Chapter 12 (Physician/Nonphysician
Practitioner Services), Section 40.7, Subsection B and C. See Appendix F.;
CMS Internet Only Manual 100-04 (Medicare Claims Processing Manual),
Chapter 23 (Fee Schedule Administration and Coding Requirements),
Addendum - MPFSDB Record Layouts. See Appendix G; CMS Internet Only
Manual, 100-04 (Medicare Claims Processing Manual), Chapter 4 (Part B
Hospital), Subsection 20.6.2. See Appendix H; Highmark Medicare Services,
Medicare A/B Reference Manual, Chapter 22, section 22.1.e.1.;
Issue Name:
Duplicate Claims - DME
Issue Number
A000772010
Issue
Description:
Identification of overpayments made on duplicate claims by DME
suppliers.
Type of Review Automated
State(s)
Affected:
NY, NJ, CT, DE, MA, MD, ME, NH, PA, RI, VT
Providers
Affected:
DME
Date Posted:
February 11, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
IOM 100-4 (Medicare Claims Processing Manual), Chapter 1 (General
Billing Requirements), Section 120, effective 7/1/2005;
Issue Name:
Medically Unlikely Units (MUE) Table
Issue
Number
A000782010
Issue
Description:
Identification of overpayments associated with providers billing the same
code in excess of units of service for the same beneficiary on the same date
of service as stipulated in CMS MUE Table.
Type of
Review
Automated
State(s)
Affected:
CT, NY, PA
Providers
Affected:
Outpatient Hospital
Date Posted: February 11, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
National Correct Coding Policy Manual, Chapter 1 General Correct Coding
Policies, Section V (NCCI V12.3 and forward).; National Correct Coding
Initiative, Medically Unlikely Edits, Outpatient Facility Services MUE Table;
CMS Manual System, Pub 100-08, Chapter 3, Subsection 3.6; CMS Manual
System, Pub 100-20 One-Time Notification, Transmittal 617, CR 6712,
Section I, Subsection B;
Issue Name:
Add-On Codes Paid without a Paid Required Primary Procedure
Issue Number A000792010
Issue
Description:
Claims overpaid for add-on codes when the required primary procedure is
not billed on any claim (same or different) for the same date of service.
Type of
Automated
Review
State(s)
Affected:
PA, NY, CT
Providers
Affected:
Outpatient Hospital
Date Posted:
February 11, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Internet Only Manual 100-04, Medicare Claims Processing Manual,
Chapter 12, Physicians/Non-Physician Practitioners, Section 30,
Subsection D, revision effective 10/1/2003;
Issue Name: Evaluation and Management Services with Allergy Services
Issue
Number
A000902010
Issue
Description:
Identification of overpayments made for Evaluation and Management
services billed without modifier 25 on the same date of service as allergy
testing or allergen immunotherapy.
Type of
Review
Automated
State(s)
Affected:
NY
Providers
Affected:
Professional Services
Date Posted: February 11, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
National Correct Coding Initiative Policy Manual for Medicare Services,
Versions 12.3 and higher, Chapter 11, Section J.3 (version 12.3 only) and
Section K.3 (versions 13.3 and higher; Internet Only Manual 100-04
(Medicare Claims Processing), Chapter 12 (Physician/Non-Physician
Practitioners), Section 200, Subsection C, revision 504, issued 3/11/2005.
Please see Appendix F.; MAC Part B - J13 - LCD L28451 Allergy
Immunotherapy, effective 1/1/2009 (Replaced LCD L28138) for New York
and Connecticut. Please see appendix G.; MAC Part B - J13 - Article
A47997 (Supplemental to LCD L28451), effective 1/1/2009 (Replaced Article
A47570) for New York and Connecticut. Please see appendix H.;
Issue Name: Incorrect Use of Modifier 51 with CPT Code 51797
Issue
Number
A001032010
Issue
Description:
Identification of underpayments associated with providers billing CPT code
51797 with modifier 51. CPT code 51797 is an add-on code that has a
Multiple Procedure Indicator of 0 (No payment adjustment rules for multiple
procedure reduction apply) and is, therefore, not subject to a payment
reduction. Audit time period from 1/1/08 - 6/30/08.
Type of
Review
Automated
State(s)
Affected:
NY
Providers
Affected:
Professional
Date Posted: February 11, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
CMS National Physician Fee Schedule Relative Value File Calendar Year for
2008, 2009 and 2010; CMS Transmittal R1528CP, CR 6087, effective May
30, 2008, changes retroactive to January 1, 2008; CMS Internet Only Manual
100-04 (Medicare Carriers Processing Manual), Chapter 12
(Physician/Nonphysician Practitioner Services), subsection 40.6.C;
Issue Name:
Anesthesia Care and Packaged Evaluation Management Services
Issue
Number
A001052010
Issue
Description:
Identification of overpayments associated with evaluation and management
services billed the day prior to or day of anesthesia services by an
anesthesiologist. 1) E/M services (as specifically defined in the IOM) billed
the day prior to or day of anesthesia services without modifiers 24, 25, or 57.
2) E/M services billed the same day as 01996 without modifiers 24, 25, or
57.
Type of
Review
Automated
State(s)
Affected:
NY
Providers
Affected:
Professional Services
Date Posted: February 11, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
National Correct Coding Initiative Policy Manual, v12.3, v13.3, v14.3,
v14.3.1, v15.3, Chapter 2, § A, B.1, B.3; CMS Publication 100-04, Chapter
12 § 50.C & F, 1/1/1998;
Issue Name:
Radiologists billing Evaluation & Management Services with Diagnostic
Mammography Services
Issue
Number
A001062010
Issue
Description:
Identification of overpayments associated with radiologists billing evaluation
and management services on the same date of service as diganostic
mammography services.
Type of
Review
Automated
State(s)
Affected:
NY, CT
Providers
Affected:
Professional Services
Date Posted: February 11, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
CMS MAC J-13, National Government Services (NGS), Part B, LCD
(L26890), original determination effective date of 7/1/2008, revision effective
date of 4/1/2010, applies to New York and Connecticut and replaced LCD
(L3500); CMS MAC J-13, Healthnow New York, Inc., LCD (L3761), original
determination effective date of 2/1/2000, revision effective date of 1/1/2007,
retired effective 8/31/2008, applies to New York only.;
Issue Name:
Verteporfin & Ocular Photodynamic Therapy without Fluoroscein
Angiography
Issue
Number
A001082010
Issue
Description:
Identification of overpayments associated with providers billing for
Verteporfin (J3396) and Ocular Photodynamic Therapy (67221-67225) in the
absence of flourescein angiography (92235) or indocyanine-green
angiography (92240) performed prior to each treatment.
Type of
Review
Automated
State(s)
Affected:
NY, PA, NJ, CT, DE, MD, DC
Providers
Affected:
Professional Services
Date Posted: February 11, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
CMS Internet Only Manual 100-03, Chapter 1, Part1, Sections 80.2 - 80.3.1.,
effective 10/3/2003. See Appendix E; CMS National Coverage
Determination for Ocular Photodynamic Therapy (OPT), 80.2, version 2,
effective 4/1/2004. See Appendix F; CMS Transmittal 9, CR 3191, posted
4/1/2004. See Appendix G;
Issue Name: Wheelchair Options and Accessories Invalid Claims Submission
Issue
Number
A001202010
Issue
Identification of paid wheelchair options and accessories that are invalid for
Description: submission to Medicare
Type of
Review
Automated
State(s)
Affected:
NJ, PA
Providers
Affected:
DME
Date Posted: February 11, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
CMS DME MAC, Jurisdiction A, Policy Article (A19829) for Wheelchair
References
Issue Name:
Options/Accessories, original effective date of 7/1/2004 and subsequent
revisions; DME MAC, Jurisdiction A, LCD (L11473) for Wheelchair
Options/Accessories, original effective date of 10/1/1993, revision date of
6/1/2007; CMS, Internet-Only Manuals (IOM), National Coverage
Determination (NCD) Manual, Pub. 100-03, Chapter 1, Part 4, Sections
280.1 and 280.3, (revision effective 5/5/05; implementation of 7/5/05), refer
to coverage provisions for Mobility Assistive Equipment (MAE);
Pulmonary Diagnostic Procedures and Evaluation & Management Services
Issue Number A001262010
Issue
Description:
Identification of overpayments associated with limited evaluation and
management services (99211-99212) billed without modifier 25 on the
same date of service as a pulmonary diagnostic procedure (94010-94799)
Type of
Review
Automated
State(s)
Affected:
CT, DC, DE, MD, NJ, NY, PA
Providers
Affected:
Professional Services
Date Posted:
February 11, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
National Correct Coding Initiative Policy Manual, v13.3; v14.3; v15.3
Chapter 11, § J.2;
Issue Name: ECGs with Cardiac Catheterization Procedures
Issue
Number
A001302010
Issue
Description:
An overpayment may exist when outpatient hospital providers bill separately
for ECGs performed the same date of service as cardiac catherization
procedures. ECGs unrelated (e.g. peformed prior to or after) the cardiac
catherization should be billed with modifier 59.
Type of
Review
Automated Review
State(s)
Affected:
DC, CT, DE, MD, NJ, NY, PA
Providers
Affected:
Outpatient Hospital
Date Posted: February 11, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
National Correct Coding Initiative Policy Manual, Chapter 11, Section I,
Subsection 2, 13, and 14, Manual Version 13.3 (Effective 10/1/2007);
National Correct Coding Initiative Policy Manual, Chapter 11 (Medicine,
Evaluation and Management Services), Section I, Subsections 3, 15, and 16.
Manual Version 14.3 (Effective 10/1/2008); National Correct Coding Initiative
Policy Manual, Chapter 11, Section I, Subsections3, 12, and 13, Manual
Version 15.3 (Effective 10/1/2009); National Correct Coding Initiative Edits Outpatient Hospital;
Medical Necessity Review (MNR) to establish whether it was medically
Issue Name: necessary to receive care in an inpatient setting- MS-DRG 641- Nutritional
and Misc. Metabolic Disorders w/o MCC
Issue
Number
A000102011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This review will be of MS DRG 641 -Nutritional and Misc. Metabolic Disorders w/o MCC.
Type of
Review
Medical Necessity Review
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospital
Date Posted: February 10, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Medical Necessity Review (MNR) to establish whether it was medically
Issue Name: necessary to receive care in an inpatient setting- MS DRG 812-Red Blood
Cell Disorders w/o MCC
Issue
Number
A000112011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This review will be of MS DRG 812 -Red Blood Cell Disorders w/o MCC.
Type of
Review
Medical Necessity Review
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: February 10, 2011
Dates of
Rolling 36 month review look back
Service:
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Medical Necessity Review (MNR) to establish whether it ws medically
Issue Name: necessary to receive care in an inpatient setting-MS-DRG 473 Cervical
Spinal Fusion w/o cc/mcc
Issue
Number
A000132011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This review will be of MS DRG 473 -Cervical Spinal Fusion w/o cc/mcc.
Type of
Review
Medical Necessity Review
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: February 10, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Issue Name: Air-fluidized Bed
Issue
Number
A001332010
Issue
Patients may have been provided a Group 3 support surface but did not
Description:
meet the clinical criteria for coverge. The medical review will determine
whether this level of treatment, utilizing an air-fluidizing bed (E0194), was
reasonable and necessary based on the patient's condition.
Type of
Review
Medical Necessity Review
State(s)
Affected:
NY, NH, MA, MD, ME, VT, PA, DE, DC, RI, CT, NJ
Providers
Affected:
DME
Date Posted: February 10, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Internet Only Manuals (IOMs), Publication 100-02, Medicare Benefit Policy
Manual, Chapter 15, Section 110, Durable Medical Equipment – General;
Internet Only Manuals (IOMs), Publication 100-08, Medicare Program
Integrity Manual, Chapter 5, Section 5.7, Documentation in the Patient’s
Medical Record; Internet Only Manual (IOMs), Publication 100-03 National
Coverage Determination (NCD) Manual: Chapter 1, Part 4, Section 280.8,
Air-Fluidized Beds; Local Coverage Determination NHIC Medicare Services,
(L5069) - LCD for Group 3 Pressure Reducing Support Surface and attached
Article (A37217); Office of Inspector General OEI-02-95-00370, June 1997 –
Pressure Reducing Support Surfaces;
Issue Name: Pneumatic Compression Device
Issue
Number
A001342010
Issue
Description:
Medical review will determine whether this level of treatment, utilizing device
(E0652), was appropriate. If the coverage criteria were not met, payment will
be based on the least costly alternative.
Type of
Review
Medical Necessity Review
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT, MD
Providers
Affected:
DME
Date Posted: February 10, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Internet Only Manuals (IOMs), Publication 100-02, Medicare Benefit Policy
Manual, Chapter 15, Section 110, Durable Medical Equipment – General;
Internet Only Manuals (IOMs), Publication 100-08, Medicare Program
Integrity Manual, Chapter 5, Section 5.7, Documentation in the Patient’s
Medical Record; Internet Only Manual (IOMs), Publication 100-03 National
Coverage Determination (NCD) Manual: Chapter 1, Part 4, 280.6, Pneumatic
Compression Devices; Transmittal R151, Change Request 1944 – Revision
to Pneumatic Compression Devices; Local Coverage Determination NHIC
Medicare Services, (L11503) - LCD for Pneumatic Compression Devices;
Office of Inspector General (OIG) Report OEI-04-97-00130, July 1998 –
Medicare Allowances for Lymphedema Pumps;
Issue Name: Power Wheelchairs (PWCs), Group 2
Issue
Number
A001352010
Issue
Description:
Group 2 Power Wheelchairs, HCPCS Codes K0823, K0825, K0827, K0829,
may have been provided to patients that did not meet the medical necessity
criteria for coverage for the power wheelchair (PWC) supplied. The review
will determine if PWC was reasonable and necessary for the patient’s
condition or if the patient should have received an alternative treatment
which may be better suited based on the documentation in the medical
record.
Type of
Review
Medical Necessity Review
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Providers
Affected:
DME
Date Posted: February 10, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Internet Only Manuals (IOMs), Publication 100-02, Medicare Benefit Policy
Manual, Chapter 15, Section 110, Durable Medical Equipment – General;
Internet Only Manuals (IOMs), Publication 100-08, Medicare Program
Integrity Manual, Chapter 5, Section 5.9.2, Evidence of Medical Necessity:
Wheelchair and Power Operated Vehicle (POV) Claims; Internet Only
Manual (IOMs), Publication 100-03 National Coverage Determination (NCD)
Manual: Chapter 1, Part 4, Section 280.3, Mobility Assisted Equipment;
Local Coverage Determination NHIC Medicare Services, (L21271) - LCD for
Power Mobility Devices and attached NHIC Medicare Services Article,
(A36239) – Power Mobility Devices; Office of Inspector General (OIG)
Report OEI-04-07-00401, December 2009 – Medicare Power Wheelchair
Claims Frequently Did Not Meet Documentation Requirements; Office of
Inspector General (OIG) Report OEI-04-07-00403, December 2007 –
Miscoded Claims for Power Wheelchairs in the Medicare Program;
MS-DRG Validation: Joint Procedures(2) 461, 480, 482, 483, 484, 485, 487,
Issue Name: 489, 492, 493, 494, 503, 504, 505, 506, 507, 508, 509, 510, 511, 512, 513,
514, 535, 536, and 906 (Medical Necessity Excluded)
Issue
Number
A001002010
Issue
Description:
MS-DRG Validation for MS-DRGs 461, 480, 482, 483, 484, 485, 487, 489,
492, 493, 494, 503, 504, 505, 506, 507, 508, 509, 510, 511, 512, 513, 514,
535, 536, and 906 MS-DRG validation requires that diagnostic and
procedural information and the discharge status of the beneficiary, as coded
on the hospital claim, matches both the attending physician description and
the information contained in the medical record. Reviewers will validate MSDRGs 461,480, 482, 483, 484, 485, 487, 489, 492, 493, 494, 503, 504, 505,
506, 507, 508, 509, 510, 511, 512, 513, 514, 535, 536 and 906 for diagnoses
and procedures affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Inpatient Hospitals
Affected:
Date Posted: February 10, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
PIM, Chapter 6.5.3 - Section A-C - Monitoring the Accuracy of Hospital
Coding (OEI-01-98-00420; 1/99) DRG Validation Review;
Issue Name:
Bilateral In Nature Procedures
Issue Number A001362010
Issue
Description:
Overpayment associated to payment for procedures that are bilateral in
nature that exceed the price of a single unit of service.
Type of
Review
Automated Review
State(s)
Affected:
NJ, NY, DC, MD, CT, PA, DE
Providers
Affected:
Professional Services
Date Posted:
February 10, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
CMS Medicare Physician Fee Schedule, Bilateral Indicator 2 (150%
payment adjustment does not apply).; CMS Internet Only Manual 100-04
(Medicare Claims Processing Manual), Chapter 12 (Physician/NonPhysician Practitioners), subsection 40.7;
Issue Name:
Colonoscopy - Excess Units
Issue
Number
A000372009
Issue
Description:
The CPT code descriptors for certain colonoscopy codes includes language
that indicates the codes should only be billed once even if multiple sites are
treated using the same technique for the same beneficiary and same date of
service. This issue identifies overpayments associated to providers billing
these colonscopy services with more than one unit of service.
Type of
Review
Automated Review
State(s)
Affected:
New York
Providers
Affected:
Outpatient Hospital
Date Posted: February 10, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
CMS RAC Demonstration Evaluation Report, June 2008, page 52; CMS
Medically Unlikely Edits, codes 45378, 45380, 45381, 45383, 45384, 45385,
45386, 45392; NCCI Policy Manual for Medicare Services, Version 15.3,
Chapter 1, Section V;
Issue Name:
Initial Infusion Services
Issue Number A000762010
Issue
Description:
Identification of overpayments associated with providers billing 'initial'
intravenous infusion (90765 and 96365), and subcutaneous infusion (90769
and 96369), with more than one unit of service by the same provider for the
same beneficiary on the same date of service.
Type of
Review
Automated Review
State(s)
Affected:
NY, CT, MD, NJ, PA
Providers
Affected:
Outpatient Hospital
Date Posted:
February 10, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
CMS Medicare Claims Processing Manual, Chapter 4, Part B Hospital,
Section 230.2; CMS Hosptial Outpatient PPS, OPPS Guidance for CY 2006;
HighMark Medicare Services, Article (A47797), revision date of 12.12.2008;
Medical Necessity Review (MNR) to establish whether it was medically
Issue Name: necessary to receive care in an inpatient setting for MS-DRG 491-Back and
Neck Procedures Except Spinal Fusion without CC/MCC
Issue
Number
A000092011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. This review will be of MS-DRG 491-Back
and Neck Procedures Except Spinal Fusion without CC/MCC.
Type of
Review
Medical Necessity Review
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospital
Date Posted: February 9, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Pepper Report "Top 20 DRGs for One-day Stays for Short-term
Acute Care Hospitals"; Medicare Inpatient Fact Sheet; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Issue Name:
Medical Necessity: Acute Inpatient Admission Neurological Disorders MSDRG's 068, 069, 070, 071, 072, 073, 074, 103, 312
Issue
Number
A001372010
Issue
Description:
RACs will review documentation to validate the medical necessity of short
stay, uncomplicated admissions. Medicare only pays for inpatient hospital
services that are medically necessary for the setting billed and that are
coded correctly. Medical documentation will be reviewed to determine that
the services were medically necessary and were billed correctly for MSDRG's, 068, 069, 070, 071, 072, 073, 074, 103 and 312.
Type of
Review
Medical Necessity Review
State(s)
Affected:
PA, DC, NJ, DE, NY, CT, VT, ME, MA, NH, RI
Providers
Affected:
Inpatient Hospitals
Date Posted: February 9, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
Medicare Program Integrity Manual Chapter 13 – Local Coverage
Determinations; Medicare Program Integrity Manual Chapter 6 - Intermediary
MR Guidelines for Specific Services; Medicare Benefit Policy Manual
Chapter 6 - Hospital Services Covered Under Part B; Medicare Benefit
Policy Manual Chapter 1 - Inpatient Hospital Services Covered Under Part A;
THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM:
An Evaluation of the 3-Year Demonstration;
Medical Necessity Review (MNR) to establish whether it was medically
Issue Name: necessary to receive care in an inpatient setting- MS DRG 039 -Extracranial
Procedures without CC/MCC
Issue
Number
A000042011
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. MS DRG 039 -Extracranial Procedures
without CC/MCC
Type of
Review
Medical Necessity Reviews
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: February 9, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
References
Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
Section 40.2.2; Local Coverage Determination Highmark Medicare Services
L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-1001000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
Report 09-88-00880 "National DRG Validation Study Unnecessary
Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
Report oai-05-88-00730 "National DRG Validation Study: Short
Hospitalizations";
Issue Name:
MS-DRG Validation: Skin Graft Connective Tissues Disorder 477, 478, 479,
515, 516, 517, 576, 577, 578, 579, 580, 581, 622, 623, 624, 904 and 905
(Medical Necessity Excluded)
Issue
Number
A000952010
Issue
Description:
MS-DRG Validation for MS-DRGs 477, 478, 479, 515, 516, 517, 576, 577,
578, 579, 580, 581, 622, 623, 624, 904 and 905 MS-DRG validation requires
that diagnostic and procedural information and the discharge status of the
beneficiary, as coded on the hospital claim, matches both the attending
physician description and the information contained in the medical record.
Reviewers will validate MS-DRGs 477, 478, 479, 515, 516, 517, 576, 577,
578, 579, 580, 581, 622, 623, 624, 904 and 905 for diagnoses and
procedures affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: January 27, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG “National DRG Validation Study Special Report on Coding Accuracy”
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040;;
Issue Name:
MS-DRG Validation: Female Reproductive Disorders MS DRGs 734, 735,
736, 737, 738, 739, 740, 741, 742, 743, 744, 745, 746, 747, 748, 749 and
750 (Medical Necessity Excluded)
Issue
Number
A000982010
Issue
Description:
MS-DRG Validation for MS-DRGs 734 - 750MS-DRG validation requires that
diagnostic and procedural information and the discharge status of the
beneficiary, as coded on the hospital claim, matches both the attending
physician description and the information contained in the medical record.
Reviewers will validate MS-DRGs 734, 735, 736, 737, 738, 739, 740, 741,
742, 743, 744, 745, 746, 747, 748, 749 and 750 for diagnoses and
procedures affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, V
Providers
Affected:
Inpatient Hospitals
Date Posted: January 27, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG “National DRG Validation Study Special Report on Coding Accuracy”
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040;;
Issue Name:
MS-DRG Validation: Disorders and Procedures of the Eye MS-DRGs 113,
114, 115, 116, 117, 121, 122, 123, 124 and 125(Medical Necessity
Excluded)
Issue
Number
A001252010
Issue
Description:
MS-DRG Validation 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-DRGs113, 114, 115, 116, 117, 121, 122, 123, 124 and 125 for
principal and secondary diagnoses and procedures affecting or potentially
affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Providers
Affected:
Inpatient Hospitals
Date Posted: January 27, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG “National DRG Validation Study Special Report on Coding Accuracy”
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040;;
Issue Name:
MS-DRG Validation: Major Cardiovascular Procedures (Medical Necessity
Excluded)
Issue
Number
A000532010
Issue
MS-DRG Validation requires that diagnostic and procedural information and
Description:
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 for MS-DRG 238; principal diagnosis, secondary diagnoses, and
procedures affecting or potentially affecting the MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Providers
Affected:
Inpatient Hospitals
Date Posted: January 14, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG “National DRG Validation Study Special Report on Coding Accuracy”
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040;;
Issue Name:
MS-DRG Validation: CAD versus Unstable Angina (Medical Necessity
Excluded)
Issue
Number
A000542010
Issue
Description:
MS-DRG Validation 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 for MS-DRG 311; principal diagnosis, secondary diagnosis and
procedures that affect or can potentially affect the MS-DRG assignment, for
the MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Providers
Affected:
Inpatient Hospitals
Date Posted: January 14, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG “National DRG Validation Study Special Report on Coding Accuracy”
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040;;
Issue Name:
MS-DRG Validation: Infectious and Parasitic Diseases (MDC 18) MS-DRGs
853, 854, 855, 856, 857, 858, 862, 863, 864, 865, 866, 867, 868, 869, 871
and 872 (Medical Necessity Excluded)
Issue
Number
A001112010
Issue
Description:
MS-DRG Validation for MS-DRGs 853, 854, 855, 856, 857, 858, 862, 863,
864, 865, 866, 867, 868, 869, 871 and 872 MS-DRG validation requires that
diagnostic and procedural information and the discharge status of the
beneficiary, as coded on the hospital claim, matches both the attending
physician description and the information contained in the medical record.
Reviewers will validate MS-DRGs 853, 854, 855, 856, 857, 858, 862, 863,
864, 865, 866, 867, 868, 869, 871 and 872 for diagnoses and procedures
affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: January 14, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG “National DRG Validation Study Special Report on Coding Accuracy”
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040;;
Issue Name:
MS-DRG Validation: Diseases and Disorders of the Nervous System (MDC
1) MS-DRGs 075, 076, 094, 095 and 096 (Medical Necessity Excluded)
Issue
Number
A001122010
Issue
Description:
MS-DRG Validation for MS-DRGs 075, 076, 094, 095 and 096 MS-DRG
validation requires that diagnostic and procedural information and the
discharge status of the beneficiary, as coded on the hospital claim, matches
both the attending physician description and the information contained in the
medical record. Reviewers will validate MS-DRGs 075, 076, 094, 095 and
096 for diagnoses and procedures affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Providers
Affected:
Inpatient Hospital
Date Posted: January 14, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG “National DRG Validation Study Special Report on Coding Accuracy”
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040;;
MS-DRG Validation: Disorders Related to Injuries/Toxicity MS-DRGs 906,
Issue Name: 913, 914, 915, 916, 917, 918, 919, 920, 921, 922 and 923 (Medical
Necessity Excluded)
Issue
Number
A001132010
Issue
Description:
MS-DRG Validation for MS-DRGs 906, 913, 914, 915, 916, 917, 918, 919,
920, 921, 922 and 923 MS-DRG validation requires that diagnostic and
procedural information and the discharge status of the beneficiary, as coded
on the hospital claim, matches both the attending physician description and
the information contained in the medical record. Reviewers will validate MSDRGs 906, 913, 914, 915, 916, 917, 918, 919, 920, 921, 922 and 923 for
diagnoses and procedures affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: January 14, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG “National DRG Validation Study Special Report on Coding Accuracy”
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040;;
Issue Name:
MS-DRG Validation: Diseases and Disorders of the Ear, Nose, Mouth and
Throat (Medical Necessity Excluded)
Issue
Number
A001242010
Issue
Description:
MS-DRG Validation 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-DRGs129, 130, 131, 132, 133, 134, 135, 136, 137, 138, 139,
146, 147, 148, 149, 150, 151, 152, 153, 154, 155, 156, 157, 158 and 159 for
principal and secondary diagnoses and procedures affecting or potentially
affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Providers
Affected:
Inpatient Hospitals
Date Posted: January 14, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG “National DRG Validation Study Special Report on Coding Accuracy”
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040;;
Issue Name:
MS-DRG Validation: Endocrine, Nutritional & Metabolic Disorders MS-DRGs
614, 615, 625, 626, 627, 628, 629 and 630 (Medical Necessity Excluded)
Issue
Number
A001012010
MS-DRG Validation for MS-DRGs 614,615,625,626,627,628,629 and 630
MS-DRG validation requires that diagnostic and procedural information and
the discharge status of the beneficiary, as coded on the hospital claim,
Issue
matches both the attending physician description and the information
Description:
contained in the medical record. Reviewers will validate MS-DRGs 614, 615,
625, 626, 627, 628, 629 and 630 for diagnoses and procedures affecting the
MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Providers
Affected:
Inpatient Hospital
Date Posted: January 14, 2011
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG “National DRG Validation Study Special Report on Coding Accuracy”
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040;;
Issue Name:
MS-DRG Validation: Major Gastrointestinal Disorders and Peritoneal
Infections (Medical Necessity Excluded)
Issue
Number
A000862010
Issue
Description:
MS-DRG Validation for MS-DRGs 371, 372, 373. Reviewers will validate the
principal diagnosis, secondary diagnosis and procedures that affect or can
potentially affect the MS-DRG assignment, for the MS-DRGs listed.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040.;
Issue Name:
MS-DRG Validation: O.R. Procedures for Obesity (Medical Necessity
Excluded)
Issue
Number
A000722010
Issue
Description:
MS-DRG Validation 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 for MS-DRGs 619, 620, 621; principal diagnosis, secondary
diagnosis and procedures that affect or can potentially affect the MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040.;
Issue Name:
MS-DRG Validation: Metastasis (Medical Necessity Excluded)
Issue
Number
A000622010
Issue
Description:
MS-DRG Validation 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 for MS-DRGs 820, 821, 822, 823, 824, 825, 840,841, 842: principal
diagnosis, secondary diagnosis and procedures that affect or can potentially
affect the MS-DRG assignment, for the MS-DRGs listed.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040.;
Issue Name:
MS-DRG Validation: Other OR Procedures for Injuries (Medical Necessity
Excluded)
Issue
Number
A000642010
Issue
Description:
MS-DRG Validation 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 for MS-DRG 907, 908, 909; principal diagnosis, secondary
diagnoses, and procedures affecting or potentially affecting the MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040.;
Issue Name:
MS-DRG Validation: Spinal Fusion (Medical Necessity Excluded)
Issue
Number
A000652010
Issue
Description:
MS-DRG Validation 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 for MS-DRGs 453, 454, 455, 456, 457, 458, 459, 460; principal
diagnosis, secondary diagnosis and procedures that affect or can potentially
affect the MS-DRG .
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040.;
Issue Name:
MS-DRG Validation: Soft Tissue Procedures (Medical Necessity Excluded)
Issue
Number
A000752010
Issue
Description:
MS-DRG Validation 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 for MS-DRGs 500, 501, 502; principal diagnosis, secondary
diagnosis and procedures that affect or can potentially affect the MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040.;
Issue Name:
MS-DRG Validation: Stomach, Esophageal and Duodenal Procedures
(Medical Necessity Excluded)
Issue
Number
A000802010
Issue
Description:
MS-DRG Validation for MS-DRGs 326, 327, 328. Reviewers will validate the
principal diagnosis, secondary diagnosis and procedures that affect or can
potentially affect the MS-DRG assignment, for the MS-DRGs listed.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040.;
Issue Name:
Pancreas, Liver and Shunt Procedures
Issue
Number
A000832010
Issue
Description:
MS-DRG Validation for MS-DRGs 405, 406, 407. Reviewers will validate the
principal diagnosis, secondary diagnosis and procedures that affect or can
potentially affect the MS-DRG assignment, for the MS-DRGs listed.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040.;
Issue Name:
MS-DRG Validation: Other Respiratory System O.R. Procedures (Medical
Necessity Excluded)
Issue
Number
A000842010
Issue
Description:
MS-DRG Validation for MS-DRGs 166, 167, 168, 264. Reviewers will
validate the principal diagnosis, secondary diagnosis and procedures that
affect or can potentially affect the MS-DRG assignment, for the MS-DRGs
listed. (ms drg added 8-6-10 CMS pre-approved)
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040.;
Issue Name:
MS-DRG Validation: Other Digestive System O.R. Procedures (Medical
Necessity Excluded)
Issue
Number
A000852010
Issue
Description:
MS-DRG Validation for MS-DRGs 356, 357, 358. Reviewers will validate the
principal diagnosis, secondary diagnosis and procedures that affect or can
potentially affect the MS-DRG assignment, for the MS-DRGs listed.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040.;
Issue Name:
MS-DRG Validation: Circulatory Disorders Except Acute Myocardial
Infarction, with Cardiac Catheterization (Medical Necessity Excluded)
Issue
Number
A000872010
Issue
Description:
MS-DRG Validation for MS-DRGs 286, 287. Reviewers will validate the
principal diagnosis, secondary diagnosis and procedures that affect or can
potentially affect the MS-DRG assignment, for the MS-DRGs listed.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040;
Issue Name:
MS-DRG Validation: Amputations 239, 240, 241, 474, 475, 476 (Medical
Necessity Excluded)
Issue
Number
A000882010
Issue
Description:
MS-DRG Validation for MS-DRGs 239, 240, 241, 474, 475, 476. Reviewers
will validate the principal diagnosis, secondary diagnosis and procedures
that affect or can potentially affect the MS-DRG assignment, for the MSDRGs listed.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040.;
Issue Name:
MS-DRG Validation: Cervical Spinal Fusions (Medical Necessity Excluded)
Issue
Number
A000892010
Issue
Description:
MS-DRG Validation for MS-DRGs 471, 472, 473, 490, 491. Reviewers will
validate the principal diagnosis, secondary diagnosis and procedures that
affect or can potentially affect the MS-DRG assignment, for the MS-DRGs
listed.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040.;
Issue Name:
MS-DRG Validation: Neoplasm Surgery MS-DRGs 826, 827, 828, 829, 830,
834, 835 and 836 (Medical Necessity Excluded)
Issue
Number
A001092010
Issue
Description:
MS-DRG Validation for MS-DRGs 826 - 830, 834 - 836 MS-DRG validation
requires that diagnostic and procedural information and the discharge status
of the beneficiary, as coded on the hospital claim, matches both the
attending physician description and the information contained in the medical
record. Reviewers will validate MS-DRGs 826, 827, 828, 829, 830, 834, 835
and 836 for diagnoses and procedures affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040.;
Issue Name:
MS-DRG Validation: Neoplasm MS-DRGs 837, 838, 839, 843, 844, 845,
846, 847, 848 and 849 (Medical Necessity Excluded)
Issue
Number
A001102010
Issue
Description:
MS-DRG Validation for MS-DRGs 837, 838, 839, 843, 844, 845, 846, 847,
848 and 849 MS-DRG validation requires that diagnostic and procedural
information and the discharge status of the beneficiary, as coded on the
hospital claim, matches both the attending physician description and the
information contained in the medical record. Reviewers will validate MSDRGs 837, 838, 839, 843, 844, 845, 846, 847, 848 and 849 for diagnoses
and procedures affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040.;
Issue Name:
MS-DRG Validation: (MDC 6) Hepatobiliary System and Pancreas Disorders
432, 433, 434, 435, 436, 437, 439, 440, 442, 443, 445 and 446 (Medical
Necessity Excluded)
Issue
Number
A001152010
Issue
Description:
MS-DRG Validation for MS-DRGs 432, 433, 434, 435, 436, 437, 439, 440,
442, 443, 445 and 446. Reviewers will validate MS-DRGs 432, 433, 434,
435, 436, 437, 439, 440, 442, 443, 445 and 446 for diagnoses and
procedures that affect the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040.;
Issue Name:
MS-DRG Validation: Carotid Artery Stent Procedures (Medical Necessity
Excluded)
Issue
Number
A001232010
Issue
Description:
MS-DRG Validation 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 034, 035 and 036 for principal and secondary diagnoses
and procedures affecting or potentially affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040.;
Issue Name:
MS-DRG Validation: Post Operative Anemia (At this time, Medical Necessity
excluded from review)
Issue
Number
A000492010
Issue
Description:
MS-DRG Validation 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 for MS-DRG 467, 481, 486, 488; principal diagnosis, secondary
diagnoses, and procedures affecting or potentially affecting the MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040;
Issue Name:
Inpatient Admissions without a Physician's Inpatient Admit Order
Issue Number A001042010
Issue
Description:
Admissions to the inpatient setting require a physician's order in order to
qualify and be paid as an inpatient stay
Type of
Review
Complex
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted:
December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
Federal Register 11-27-2006 (42 CFR Part 482) page 2, requires
authentication of orders for the care of the patient by a physician/ provider;
Medicare Benefit Policy Manual – Chapter 1 Section 10; Claims Processing
Manual Chapter 3 Section 10 and 40.2.2;
Issue Name:
Place of Service Coding for Physician Services
Issue Number A009002010
Issue
Description:
There are certain services that cannot be performed in an ASC and in a
physician office on the same date of service for the same patient.
Type of
Review
Automated Review
State(s)
Affected:
CT, DC, DE MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Professional Services
Date Posted:
December 7, 2010
Dates of
Rolling 36 month review look back
Service:
Issue
References
OIG Report: Review of Place of Service Coding for Physician Services #A01-08-00528 OIG Report: Review of Place of Service Coding for Physician
Services # A-01-08-00528 IOM 100-04 Chapter 12 Section 20.4.2;
Issue Name: Medical Necessity Review (MNR) - Renal and Urinary Tract Disorders
Issue
Number
A001282010
Issue
Description:
Medicare pays for inpatient hospital services that are medically necessary for
the setting billed. Medical documentation will be reviewed to determine that
services were medically necessary. MS-DRG: 657, 658, 660, 661, 663, 664,
666, 667-670, 673-675, 682-685, 691-700.
Type of
Review
Medical Necessity Review
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Part A
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
Program Integrity Manual (PIM) Chapter 6.5.2;; Medicare Program Integrity
Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
Policy Manual Chapter 1, section 10;; Medicare Benefit Policy Manual
Chapter 11, Section 20; Claims Processing Manual Chp 3, Section 40.2.2;
Local Coverage Determination Highmark Medicare Services L27548;
Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for One-day
Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-01000 July
2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG Report 09-8800880 "National DRG Validation Study Unnecessary Admissions to
Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA PA Regional
Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG Report oai-0588-00730 "National DRG Validation Study: Short Hospitalizations";
Issue Name:
MS-DRG Validation: Urinary Procedures (Medical Necessity Excluded)
Issue
Number
A000662010
Issue
Description:
MS-DRG Validation 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 for MS-DRGs 653, 654, 655, 656, 657, 658, 659, 660, 661, 662,
663, 664, 665, 666, 667, 668, 669, 670, 671, 672, 673, 674, 675; principal
diagnosis, secondary diagnoses, and procedures affecting or potentially
affecting the MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: December 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG "National DRG Validation Study Special Report on Coding Accuracy",
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040;
Issue Name:
Musculoskeletal Fractures (At this time, medical necessity is excluded from
the review)
Issue
Number
A000912010
Issue
Description:
MS-DRG Validation for MS-DRGs 533, 534, 537, 538, 562 and 563 MS-DRG
validation requires that diagnostic and procedural information and the
discharge status of the beneficiary, as coded on the hospital claim, matches
both the attending physician description and the information contained in the
medical record. Reviewers will validate MS-DRGs 533, 534, 537, 538, 562
and 563 for diagnoses and procedures affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: October 27, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim); ICD-9-CM
Addendums & AHAs Coding Clinics; PIM, Chapter 6.5.3 - Section A-C Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99) DRG
Validation Review; UHDDS - Reporting of Inpatient Data Elements, July 31,
1985; Federal Register (Vol.50, No. 147) Pages 31038-31040.;
Issue Name:
Nervous System Procedures (At this time, medical necessity is excluded
from the review)
Issue
Number
A000942010
Issue
Description:
MS-DRG validation requires that diagnostic and procedural information and
the discharge status of the beneficiary, as coded on the hospital claim,
matches both the attending physician description and the information
contained in the medical record. Reviewers will validate the principal and
secondary diagnoses and procedures affecting or potentially affecting
assignment of MS DRGs 020, 021, 022, 023, 024, 028, 029, 030, 031, 032,
033, 037, 038, 039, 040, 041 and 042.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: October 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG report “National DRG Validation Study Special Report on Coding
Accuracy”, OAI-12-88-01010, which indicated that 20.8% of claims were
submitted with incorrect DRGs; ICD-9-CM Coding Manual ( for dates of
service on claim), ICD-9-CM Addendums and Coding Clinics, PIM Chapter
6.5.3 Section A - C DRG Validation Review, UHDDS - Reporting of inpatient
Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages
31038-31040.;
Issue Name:
Cataract Removal - Excess Units
Issue Number A000672010
Issue
Description:
Cataract removal can only occur once per eye for the same date of service.
This issue identifies overpayments associated to outpatient hospital
providers billing more than on unit of cataract removal for the same eye.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
MA, MD, ME, NH, NY, PA, RI VT
Providers
Affected:
Outpatient Hospitals
Date Posted:
October 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
Internet Only Manual 100-08 (Program Integrity Manual), Chapter 3,
Subsection 3.6; NCCI Policy Manual for Medicare Services, version 15.3.
Chapter 8, Section D, #3;
Issue Name: National Correct Coding Initiative (CCI) - OPPS
Issue
Number
A000112009
Issue
Description:
Application of the OPPS National Correct Coding Initiative (Mutually
Exclusive and Non-Mutually Exclusive). Deny Column II code when billed by
the same provider and same date of service as a Column I code.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, NJ, NY, PA
Providers
Affected:
Outpatient Hospitals
Date Posted: September 28, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
Internet Only Manual 100-04 Medicare Claims Processing Manual, Chapter
23 (Fee Schedule Administration and Coding Requirements), Subsection
20.9 (Correct Coding Initiative), revision effective 10/1/2003; Column
I/Column II code pairs are date sensitive. 2) Integrated Outpatient Code
Editor Software, versions 8.3 (effective 10/1/2007) and higher, edit #s 19, 20,
39, and 40.; NCCI Edits - Hospital Outpatient PPS; Outpatient Code Editor Overview;
Issue Name:
Respiratory (At this time, medical necessity validation limited to MS-DRG
190, 191, and 192)
Issue
Number
A001022010
Issue
Description:
Reviewers will validate the principal diagnosis, secondary diagnosis and
procedures that affect or can potentially affect the MS-DRG assignment, for
the MS-DRGs175, 176, 179, 180, 181, 182, 183, 184, 185, 186, 187, 188,
190, 191, 192, 194, 195, 196, 197, 198, 199, 200, 201, 202, 203, 204, 205,
206 and 208 for diagnoses and procedures affecting the MS-DRG
assignment. Additionally, MS- DRGs 190, 191 and 192 will be review for
medical necessity.
Type of
Review
DRG Coding and Medical Necessity Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: September 9, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG report “National DRG Validation Study Special Report on Coding
Accuracy”, OAI-12-88-01010, which indicated that 20.8% of claims were
submitted with incorrect DRGs; ICD-9-CM Coding Manual ( for dates of
service on claim), ICD-9-CM Addendums and Coding Clinics, PIM Chapter
6.5.3 Section A – C DRG Validation Review, UHDDS – Reporting of inpatient
Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages
31038-31040; Section 1886(d) of the Social Security Act (Public Law 98-21);
Medicare Program Integrity Manual (PIM) Chapter 6.5.2; PIM Chapter 13
Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit Policy Manual Chapter 1,
section 10; Medicare Benefit Policy Manual Chapter 6, Section 20.6;
Medicare Claims Processing Manual Chapter 4, Sections 290.1 and 290.2.2;
Issue Name:
Gastro Intestinal Disorders. (At this time, medical necessity validation limited
to MS-DRGs 391 and 393)
Issue
Number
A000962010
Issue
Description:
MS-DRG validation requires that diagnostic and procedural information and
the discharge status of the beneficiary, as coded on the hospital claim,
matches both the attending physician description and the information
contained in the medical record. Reviewers will validate MS-DRGs 332, 333,
334, 338, 339, 340, 341, 342, 343, 344, 345, 346, 347, 348, 349, 368, 369,
370, 374, 375, 376, 377, 378, 379, 380, 381, 382, 383, 384, 385, 386, 387,
388, 389, 390, 391, 392, 393, 394 and 395 for diagnoses and procedures
affecting the MS-DRG assignment. Additionally, medical records for MS
DRGs 391 and 393 will be reviewed for medical necessity.
Type of
Review
DRG Coding and Medical Necessity Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: September 9, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
1) OIG report “National DRG Validation Study Special Report on Coding
Accuracy”, OAI-12-88-01010, 2) Office of the Inspector General (OIG)
Report A01-10-01000, 3) OIG Report OAI 09-88-00880, 4) OIG Report A-0300-00007 and 5) OIG Report OAI 05-88-00730. 1) Section 1886(d) of the
Social Security Act (Public Law 98-21); 2) CMS Internet-Only Manuals
(IOMs), Publication 100-08; Medicare Program Integrity Manual (PIM),
Chapter 6, Section 6.5.2 and 6.5.3; 3) Medicare Program Integrity Manual
(PIM) Chapter 13 Sections 13.1, 13.1.1 and 13.1.3; 4) Medicare Benefit
Policy Manual Chapter 1, Section 10; 5) Medicare Benefit Policy Manual
Chapter 6, Section 20.6; 6) CMS IOM, Publication 100-04, Medicare Claims
Processing Manual, Chapter 3, Section 40.2.2 (K); 7) Medicare Claims
Processing Manual Chapter 4, Sections 290.1 and 290.2.2; 8) ICD-9-CM
Coding Manual (for dates of service on claim); 9) ICD-9-CM Addendums and
Coding Clinics; Uniform Hospital Discharge Data Set (UHDDS) – Reporting
of Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No.
147), Pages 31038-31040.;
Issue Name:
Diseases and Disorders of Blood, Blood Forming Organs and Immunological
Disorders (At this time, medical necessity validation limited to MS-DRG 811)
Issue
Number
A001182010
Issue
Description:
MS-DRG Validation for MS-DRGs 799, 800, 801, 802, 803, 804, 808, 809,
810, 811, 812, 813, 814, 815 and 816 (MDC 16) MS-DRG validation requires
that diagnostic and procedural information and the discharge status of the
beneficiary, as coded on the hospital claim, matches both the attending
physician description and the information contained in the medical record.
Reviewers will validate MS-DRGs 799, 800, 801, 802, 803, 804, 808, 809,
810, 811, 812, 813, 814, 815 and 816 for diagnoses and procedures
affecting the MS-DRG assignment. Additionally, medical records for MS
DRG 811 will be reviewed for medical necessity.
Type of
Review
DRG Coding and Medical Necessity Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: September 9, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
1) OIG report “National DRG Validation Study Special Report on Coding
Accuracy”, OAI-12-88-01010, 2) Office of the Inspector General (OIG)
Report A01-10-01000, 3) OIG Report OAI 09-88-00880, 4) OIG Report A-0300-00007 and 5) OIG Report OAI 05-88-00730. 1) Section 1886(d) of the
Social Security Act (Public Law 98-21); 2) CMS Internet-Only Manuals
(IOMs), Publication 100-08; Medicare Program Integrity Manual (PIM),
Chapter 6, Section 6.5.2 and 6.5.3; 3) Medicare Program Integrity Manual
(PIM) Chapter 13 Sections 13.1, 13.1.1 and 13.1.3; 4) Medicare Benefit
Policy Manual Chapter 1, Section 10; 5) Medicare Benefit Policy Manual
Chapter 6, Section 20.6; 6) CMS IOM, Publication 100-04, Medicare Claims
Processing Manual, Chapter 3, Section 40.2.2 (K); 7) Medicare Claims
Processing Manual Chapter 4, Sections 290.1 and 290.2.2; 8) ICD-9-CM
Coding Manual (for dates of service on claim); 9) ICD-9-CM Addendums and
Coding Clinics; Uniform Hospital Discharge Data Set (UHDDS) - Reporting
of Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No.
147), Pages 31038-31040.;
Issue Name:
Endocrine, Nutritional & Metabolic Disorders II (At this time, medical
necessity validation limited to MS-DRG 640)
Issue
Number
A001162010
Issue
Description:
MS-DRG Validation for MS-DRGs MS-DRGs 616, 617,618, 619,620,621,
622, 623, 624, 637, 638, 639, 640, 641, 642, 643, 644 and 645. MS-DRG
validation requires that diagnostic and procedural information and the
discharge status of the beneficiary, as coded on the hospital claim, matches
both the attending physician description and the information contained in the
medical record. Reviewers will validate MS-DRGs 616, 617,618,
619,620,621, 622, 623, 624, 637, 638, 639, 640, 641, 642, 643, 644 and 645
for diagnoses and procedures affecting the MS-DRG assignment.
Additionally, medical records for MS DRG 640 will be reviewed for medical
necessity.
Type of
Review
DRG Coding and Medical Necessity Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: September 9, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
1) OIG report “National DRG Validation Study Special Report on Coding
Accuracy”, OAI-12-88-01010, 2) Office of the Inspector General (OIG)
Report A01-10-01000, 3) OIG Report OAI 09-88-00880, 4) OIG Report A-0300-00007 and 5) OIG Report OAI 05-88-00730. 1) Section 1886(d) of the
Social Security Act (Public Law 98-21); 2) CMS Internet-Only Manuals
(IOMs), Publication 100-08; Medicare Program Integrity Manual (PIM),
Chapter 6, Section 6.5.2 and 6.5.3; 3) Medicare Program Integrity Manual
(PIM) Chapter 13 Sections 13.1, 13.1.1 and 13.1.3; 4) Medicare Benefit
Policy Manual Chapter 1, Section 10; 5) Medicare Benefit Policy Manual
Chapter 6, Section 20.6; 6) CMS IOM, Publication 100-04, Medicare Claims
Processing Manual, Chapter 3, Section 40.2.2 (K); 7) Medicare Claims
Processing Manual Chapter 4, Sections 290.1 and 290.2.2; 8) ICD-9-CM
Coding Manual (for dates of service on claim); 9) ICD-9-CM Addendums and
Coding Clinics; Uniform Hospital Discharge Data Set (UHDDS) - Reporting
of Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No.
147), Pages 31038-31040.;
Issue Name:
Percutaneous Cardiovascular Procedures (At this time, medical necessity
validation limited to MS-DRG 249)
Issue
Number
A000822010
Issue
Description:
MS-DRG Validation for MS-DRGs 246, 247, 249, 251. MS-DRG validation
requires that diagnostic and procedural information and the discharge status
of the beneficiary, as coded on the hospital claim, matches both the
attending physician description and the information contained in the medical
record. Reviewers will validate the principal diagnosis, secondary diagnosis
and procedures that affect or can potentially affect the MS-DRG assignment,
for the MS-DRGs listed. Additionally, medical records for MS DRG 249 will
be reviewed for medical necessity.
Type of
Review
DRG Coding and Medical Necessity Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: September 9, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG report “National DRG Validation Study Special Report on Coding
Accuracy”, OAI-12-88-01010, which indicated that 20.8% of claims were
submitted with incorrect DRGs; ICD-9-CM Coding Manual ( for dates of
service on claim), ICD-9-CM Addendums and Coding Clinics, PIM Chapter
6.5.3 Section A - C DRG Validation Review, UHDDS - Reporting of inpatient
Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages
31038-31040.;
Issue Name:
Nervous System Disorders (At this time, medical necessity validation limited
to MS-DRGs 056 and 057)
Issue
Number
A000922010
Issue
Description:
MS-DRG validation requires that diagnostic and procedural information and
the discharge status of the beneficiary, as coded on the hospital claim,
matches both the attending physician description and the information
contained in the medical record. Reviewers will validate MS-DRGs 052, 053,
054, 055, 056, 057, 058, 059, 060, 070, 071, 072, 073, 074, 077, 078, 079,
080, 081, 082, 083, 084, 085, 086, 087, 088, 089, 090, 091, 092, 093, 097,
098, 099, 102 and 103 for diagnoses and procedures affecting the MS-DRG
assignment. Additionally, medical records for MS DRGs 056 and 057 will be
reviewed for medical necessity.
Type of
Review
DRG Coding and Medical Necessity Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: September 9, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim); ICD-9-CM
Addendums & AHA Coding Clinics; PIM, Chapter 6.5.3 - Section A-C Monitoring the Accuracy of Hospital Coding (OEI-01-98-0420; 1/99) DRG
Validation Review; UHDDS - Reporting of Inpatient Data Elements, July 31,
1985; Federal Register (Vol.50, No.147) Pages 31038-31040; Section
1886(d) of the Social Security Act (Public Law 98-21); Medicare Program
Integrity Manual (PIM) Chapter 6.5.2; PIM Chapter 13 Section 13.1, 13.1.1,
and 13.1.3; Medicare Benefit Policy Manual Chapter 1, section 10; Medicare
Benefit Policy Manual Chapter 6, Section 20.6; Medicare Claims Processing
Manual Chapter 4, Sections 290.1 and 290.2.2;
Issue Name:
Musculoskeletal Disorders (At this time, medical necessity validation limited
to MS-DRGs 551 and 552)
Issue
Number
A000932010
Issue
Description:
MS-DRG Validation for MS-DRGs 539, 540, 541, 545, 546, 547, 548, 549,
550, 551, 552, 553, 554, 555, 556, 557, 558, 564, 565 and 566 MS-DRG
validation requires that diagnostic and procedural information and the
discharge status of the beneficiary, as coded on the hospital claim, matches
both the attending physician description and the information contained in the
medical record. Reviewers will validate MS-DRGs 539, 540, 541, 545, 546,
547, 548, 549, 550, 551, 552, 553, 554, 555, 556, 557, 558, 564, 565 and
566 for diagnoses and procedures affecting the MS-DRG assignment.
Additionally, medical records for MS DRGs 551 and 552 will be reviewed for
medical necessity.
Type of
Review
DRG Validation and Medical Necessity Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: September 9, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim); ICD-9-CM
Addendums & AHAs Coding Clinics; PIM, Chapter 6.5.3 - Section A-C Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99) DRG
Validation Review; UHDDS - Reporting of Inpatient Data Elements, July 31,
1985; Federal Register (Vol.50, No. 147) Pages 31038-31040; Section
1886(d) of the Social Security Act (Public Law 98-21); Medicare Program
Integrity Manual (PIM) Chapter 6.5.2; PIM Chapter 13 Section 13.1, 13.1.1,
and 13.1.3; Medicare Benefit Policy Manual Chapter 1, section 10; Medicare
Benefit Policy Manual Chapter 6, Section 20.6; Medicare Claims Processing
Manual Chapter 4, Sections 290.1 and 290.2.2;
Issue Name:
Kidney and Urinary Tract Disorders 683, 684, 685, 686, 687, 688, 690, 695,
696, 697, 698, 699 and 700 (At this time, medical necessity limited to MSDRGs 683 and 684)
Issue
A000972010
Number
Issue
Description:
MS-DRG validation requires that diagnostic and procedural information and
the discharge status of the beneficiary, as coded on the hospital claim,
matches both the attending physician description and the information
contained in the medical record. Reviewers will validate MS-DRGs 683, 684,
685, 686, 687, 688, 690, 695, 696, 697, 698, 699 and 700 for diagnoses and
procedures affecting the MS-DRG assignment. Additionally, medical records
for MS DRGs 683 and 684 will be reviewed for medical necessity.
Type of
Review
DRG Coding and Medical Necessity Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: September 9, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim); ICD-9-CM
Addendums & AHAs Coding Clinics; PIM, Chapter 6.5.3 - Section A-C Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99) DRG
Validation Review; UHDDS - Reporting of Inpatient Data Elements, July 31,
1985; Federal Register (Vol.50, No. 147) Pages 31038-31040; Section
1886(d) of the Social Security Act (Public Law 98-21), 2) Medicare Program
Integrity Manual (PIM) Chapter 6.5.2; PIM Chapter 13 Section 13.1, 13.1.1,
and 13.1.3; Medicare Benefit Policy Manual Chapter 1, section 10; Medicare
Benefit Policy Manual Chapter 6, Section 20.6; Medicare Claims Processing
Manual Chapter 4, Sections 290.1 and 290.2.2;
Issue Name:
Diseases & Disorders of the Circulatory System. (At this time, medical
necessity limited to MS-DRGs 253, 254, 292, 293, 302, 308 and 312-316)
Issue
Number
A001172010
Issue
Description:
MS-DRG validation requires that diagnostic and procedural information and
the discharge status of the beneficiary, as coded on the hospital claim,
matches both the attending physician description and the information
contained in the medical record. Reviewers will validate MS-DRGs 215, 229,
230, 232, 252-257,263, 265- 285, 288-290, 292-310 and 312-316 for
diagnoses and procedures affecting the MS-DRG assignment. Additionally,
medical records for MS DRGs 253, 254, 292, 293, 302, 308 and 312-316 will
be reviewed for medical necessity.
Type of
Review
DRG Coding and Medical Necessity Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: September 9, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG “National DRG Validation Study Special Report on Coding Accuracy”
OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
Register (Vol.50, No. 147), Pages 31038-31040;;
Issue Name:
National Correct Coding Initiative (CCI) - Part B for Ambulatory Surgical
Centers
Issue
Number
A000102009
Issue
Description:
Application of the Part B National Correct Coding Initiative (Mutually
Exclusive and Non-Mutually Exclusive) to Ambulatory Surgical Centers.
Deny Column II code when billed by the same provider and same date of
service as a Column I code.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MD, NJ, NY, PA
Providers
Affected:
Ambulatory Surgical Centers
Date Posted: August 24, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
Internet Only Manual 100-04 Medicare Claims Processing Manual, Chapter
23 (Fee Schedule Administration and Coding Requirements), Subsection
20.9 (Correct Coding Initiative), revision effective 10/1/2003;; Internet Only
Manual 100-4 Medicare Claims Processing Manual, Chapter 14 (Ambulatory
Surgical Centers), Subsection 20.9 (Rebundling of CPT codes); revision
effective 10/1/2003. Column I/Column II code pairs are date sensitive.;
Issue Name:
MS-DRG Validation for Major Chest Procedures (At this time, medical
necessity is excluded from review)
Issue
Number
A000392009
Issue
Description:
MS-DRG Validation 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 for MSDRG 163, 164, 165, principal diagnosis, secondary diagnosis,
and procedures affecting or potentially affecting the MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
OIG report “National DRG Validation Study Special Report on Coding
Accuracy”, OAI-12-88-01010, which indicated that 20.8% of claims were
submitted with incorrect DRGs; ICD-9-CM Coding Manual ( for dates of
service on claim), ICD-9-CM Addendums and Coding Clinics, PIM Chapter
6.5.3 Section A - C DRG Validation Review, UHDDS - Reporting of inpatient
Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages
31038-31040.;
Issue Name:
MS-DRG Validation for Extensive OR Procedure (At this time, medical
necessity is excluded from review)
Issue
Number
A000442009
Issue
Description:
MS-DRG Validation 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-DRG 981, 982 and 983 for principal and secondary diagnosis
and procedures affecting or potentially affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, UHDDS Reporting of
Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 127),
Pages 31038-31040;
Issue Name:
MS-DRG Validation for Complications of Cholecystectomy (At this time
medical necessity is excluded from review)
Issue
Number
A000572010
Issue
Description:
MS-DRG Validation 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 411, 412, 413, 414, 415, 416, 417, 418, and 419 for
principal and secondary diagnoses and procedures affecting or potentially
affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Rolling 36 month review look back
Service:
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim). ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics. PIM 6.5.3 A-C DRG Validation Review, Uniform Hospital Discharge
Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31, 1985,
Federal Register (Vol. 50, No. 127), Pages 31038-31040;
Issue Name:
MS-DRG Validation for Craniotomy and Endovascular Intracranial
procedures (At the time, medical necessity is excluded from review)
Issue
Number
A000592010
Issue
Description:
MS-DRG Validation 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-DRG 025, 026 and 027 for principal and secondary diagnosis
and procedures affecting or potentially affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, Uniform Hospital
Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31,
1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040;
Issue Name:
MS-DRG Validation for Joint Procedures (At this time, medical necessity is
excluded from review)
Issue
Number
A000602010
Issue
Description:
MS-DRG Validation 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-DRG 462, 466, 467, 468, 469 and 470 for principal and
secondary diagnosis and procedures affecting or potentially affecting the
MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, Uniform Hospital
Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31,
1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040;
Issue Name:
MS-DRG Validation for Non-extensive O.R. Procedure Unrelated to Principal
Diagnosis (At this time medical necessity is excluded from review)
Issue
Number
A000632010
Issue
Description:
MS-DRG Validation 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-DRG 987, 988 and 989 for principal and secondary diagnosis
and procedures affecting or potentially affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, Uniform Hospital
Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31,
1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040;
Issue Name:
MS-DRG Validation for Hip and Femur Procedures (At this time medical
necessity is excluded from review)
Issue
Number
A000712010
Issue
Description:
MS-DRG Validation 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 495, 496, 497, 498 and 499 for principal and secondary
diagnosis and procedures affecting or potentially affecting the MS-DRG
assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, Uniform Hospital
Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31,
1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040;
Issue Name:
MS-DRG Validation for Pathological Fractures (At this time, medical
necessity is excluded from review)
Issue
Number
A000732010
Issue
Description:
MS-DRG Validation 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 for MS-DRGs 542, 543, 544; principal diagnosis, secondary
diagnosis and procedures that affect or can potentially affect the MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
Addendums and Coding Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review,
Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
Elements, July 31, 1985, Federal Register (Vol. 50, No. 127), Pages 3103831040;
Issue Name:
MS-DRG Validation for Seizures (At this time, medical necessity is excluded
from review)
Issue
Number
A000742010
Issue
Description:
MS-DRG Validation 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 for MS-DRGs 100, 101; principal diagnosis, secondary diagnosis
and procedures that affect or can potentially affect the MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
Addendums and Coding Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review,
Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
Elements, July 31, 1985, Federal Register (Vol. 50, No. 127), Pages 3103831040;
Issue Name:
Date of Death-DME
Issue Number A009012010
Issue
Description:
Medicare does not typically pay for services or equipment provided after
the beneficiary's date of death.
Type of
Review
Automated
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
DME Suppliers
Date Posted:
August 11, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
IOM Publication 100-01 Chapter 2 Section 40.5; IOM Publication 100-4
Chapter 20 Section 30.5.4; IOM Publication 100-02, Chapter 15 , Section
110.1; OIG Report March 2000 – OEI-03-99-00200;
Issue Name:
Date of Death-Inpatient
Issue Number
A009022010
Issue
Description:
Medicare does not typically pay for services or equipment rendered after
the beneficiary's date of death.
Type of Review Complex
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted:
August 11, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
IOM Publication 100-01 Chapter 2 Section 40.5; IOM Publication 100-04
Chapter 3 Section 40.2.2; OIG Report March 2000 – OEI-03-99-00200;
Issue Name:
Technical Component of Radiology
Issue
A000232009
Number
Issue
Description:
A potential vulnerability may exist when the technical component (TC) of
radiology services are furnished to patients in a Prospective Payment
System (PPS) hospital setting and are billed separately to Part B. Therefore,
an issue may exist when these codes are billed and are reimbursed under
Medicare Part B in this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted: June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
IOM 100-04. Chapter 13. Section 20.2.1, OIG Report A-01-04-00528;
Issue Name:
Severe Sepsis (At this time, medical necessity validation limited to MS-DRGs
291, 682, and 689)
Issue
Number
A000382009
Issue
Description:
MS-DRG Validation 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 for MS DRGs 177, 189, 193, 291, 438, 441, 444, 592, 602, 682,
689, 691, 693; principal diagnosis, secondary diagnosis, and procedures
affecting or potentially affecting the MS-DRG. Additionally, medical records
for MS DRGs 291, 682, and 689 will be reviewed for medical necessity as of
September 9, 2010.
Type of
Review
DRG Coding and Medical Necessity Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-Cm Coding Manual (for dates of service on claim), ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinic, PIM Chapter 6.5.3 A-C DRG Validation Review, UHDDS Reporting of
Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 127)
Pages 31038-31040. The Medicare Recovery Audit Contractor (RAC)
Demonstration Table P3 and Table P4, Page 57. OIG Report OEI-03-9800370, March 1999; Section 1886(d) of the Social Security Act (Public Law
98-21); Medicare Program Integrity Manual (PIM) Chapter 6.5.2; PIM
Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit Policy Manual
Chapter 1, section 10; Medicare Benefit Policy Manual Chapter 6, Section
20.6; Medicare Claims Processing Manual Chapter 4, Sections 290.1 and
290.2.2;
Issue Name:
MS-DRG Validation for Cardiac Valve Procedures (At this time, medical
necessity is excluded from review)
Issue
Number
A000562010
Issue
Description:
DRG Validation 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 for MS-DRGs 216, 217, 218, 219, 220, and 221, principal diagnosis,
secondary diagnosis, and procedures affecting or potentially affecting the
DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, Uniform Hospital
Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31,
1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040;
Issue Name:
MS-DRG Validation for Coronary Bypass (At this time, medical necessity is
excluded from review)
Issue
Number
A000582010
Issue
Description:
DRG Validation 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 for MS-DRGs 234 and 236, principal diagnosis, secondary
diagnosis, and procedures affecting or potentially affecting the DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim). ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics. PIM 6.5.3 A-C DRG Validation Review, Uniform Hospital Discharge
Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31, 1985,
Federal Register (Vol. 50, No. 127), Pages 31038-31040;
Issue Name:
MS-DRG Validation for Lysis of Adhesions (At this time, medical necessity is
excluded from review)
Issue
Number
A000612010
Issue
Description:
DRG Validation 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 for MS-DRGs 335, 336, 337, 350, 351, 352, 353, 354, and 355,
principal diagnosis, secondary diagnosis, and procedures affecting or
potentially affecting the DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim). ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics. PIM 6.5.3 A-C DRG Validation Review, Uniform Hospital Discharge
Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31, 1985,
Federal Register (Vol. 50, No. 127), Pages 31038-31040;
Issue Name:
MS-DRG Validation for Excisional Debridement (At this time, medical
necessity is excluded from review)
Issue
Number
A000452009
Issue
Description:
DRG Validation 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 for MS-DRGs 463, 464, 465, 573, 574, 575, 901, 902, and 903,
principal diagnosis, secondary diagnosis, and procedures affecting or
potentially affecting the DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM addendums and Coding
Clinics, PIM 6.5.3 A-C DRG Validation Review, UHDDS Reporting of
Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 127),
Pages 31038-31040). The Medicare Recovery Audit Contractor (RAC)
Demonstration Table G1, Page 44, Table HI, Page 45 and Appendix P1
Page 56;
Issue Name:
Global vs. TC/PC Split Reimbursements
Issue
Number
A000212009
Issue
Description:
A potential vulnerability may exist when providers are reimbursed for global
procedures and then receive additional reimbursement for technical (modifier
TC) and/or professional (modifier 26) components for the same service.
Therefore, an issue may exist when these codes are billed and are
reimbursed under Medicare Part B in this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted: June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
IOM 100-04, Chapter 1, Section 120; IOM 100-04, Chapter 12, Section 20.2;
IOM 100-04, Chapter 13, Section 20.1-20.2.3; IOM 100-04, Chapter 16,
pages 80.2.1;
Issue Name:
IV Hydration
Issue Number A000182009
Issue
Description:
A potential vulnerability may exist if certain IV Hydration Codes are billed for
more than one unit per date of service. Therefore, an issue may exist when
these codes are billed and are reimbursed under Medicare Part B in this
manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
IOM 100-04, Chapter 12, pages 31-32; IOM 100-20, Transmittal 419, page
7;
Issue Name:
Bronchoscopy Services
Issue Number A000172009
Issue
Description:
A potential vulnerability may exist if certain bronchoscopy services are billed
for more than one unit per date of service. Therefore, an issue may exist
when these codes are billed and are reimbursed under Medicare Part B in
this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
Federal Register, Volume 67, No. 251, page 8;
Issue Name:
Blood Transfusions
Issue Number A000162009
Issue
Description:
A potential vulnerability may exist if certain blood transfusion codes are
billed for more than one unit per date of service. Therefore, an issue may
exist when these codes are billed and are reimbursed under Medicare Part
B in this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
IOM 100-04, Chapter 4, Section 231.8;
Issue Name:
Untimed Codes
Issue Number A000152009
Issue
Description:
A potential vulnerability may exist if certain codes are billed for more than
one unit. Therefore, an issue may exist when these codes are billed and
are reimbursed under Medicare Part B in this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
IOM 100-04, Chapter 5, Section 20.2; IOM 100-04, Transmittal 1019, dated
8.3.06, pages 7-11;
Issue Name:
Neulasta
Issue Number A000142009
Issue
Description:
A potential vulnerability may exist if the code J2505 is billed with more than
1 unit per patient per date of service. Therefore, an issue may exist when
these codes are billed and are reimbursed under Medicare Part B inside of
this time frame.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
IOM 100-04, Transmittal 949 (dated May 12, 2006), HCPCS Level II 2007,
2008, 2009;
Issue Name:
Once In A Lifetime
Issue Number A000132009
Issue
Description:
Certain codes may only be billed once in a lifetime. Therefore, an issue
may exist when these codes are billed and are reimbursed under Medicare
Part B inside of this time frame.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
References IOM 100-08, Chapter 3 Section 3.6.;
Issue Name:
Newborn/Pediatric Codes
Issue Number A000122009
Issue
Providers should not bill new Newborn/Pediatric Codes for patients which
Description:
exceed the age limit defined by the CPT Code. Therefore, an issue may
exist when Newborn/Pediatric Codes and are reimbursed under Medicare
Part B outside of the age limit.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
American Medical Association (AMA), Current Procedural Terminology
2007, 2008, 2009;
Issue Name:
New Patient Visits
Issue Number A000072009
Issue
Description:
Providers should not bill new patient Evaluation and Management services
on the same beneficiary within a 3 year period of time. Therefore, an issue
may exist when multiple new patient E&M services and are reimbursed
under Medicare Part B inside of this time frame.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MD, NJ, NY, PA
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
IOM 100-04 Chapter 12, Section 30.6.7;
Issue Name:
Duplicate Claims - Part B
Issue Number
A000462009
Issue
Description:
Providers should not bill duplicate claims. Therefore, an issue may exist
when duplicate services are billed and reimbursed under Medicare Part B.
Type of Review Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MD, NJ, NY, PA
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
IOM 100-04 Chapter 1, Section 120;
References
Issue Name:
Global Billing of Radiology or Diagnostic Tests in the Facility Setting
Issue Number A000092009
Issue
Description:
Providers should not bill diagnostic tests and radiology services globally in
the facility setting. Therefore, an issue may exist when these services are
billed globally and reimbursed under Medicare Part B.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
NY
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
IOM 100-04 Chapter 13, Section 20.2.1; IOM 100-04 Chapter 23;
Issue Name:
Global Surgery - Pre and Post-Operative Visits
Issue Number A000032009
Issue
Description:
E&M services are not allowed to be billed prior to a major surgical service
without the proper modifiers. Therefore, an issue may exist when these
services are billed and reimbursed under Medicare Part B without these
modifiers.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MD, NJ, NY, PA
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
IOM 100-04 Chapter 12, Section 40.1, 40.3;
Issue Name:
National Correct Coding Initiative - Part B
Issue Number A000022009
Issue
Description:
A provider may not bill a Column II code when billed by the same provider
and same date of service as a Column I code. Therefore, an issue may
exist when Column II codes are billed and reimbursed under Medicare Part
B in this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MD, NJ, NY, PA
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
IOM 100-04 Chapter 12, Section 30; IOM 100-04 Chapter 23, Section 20.9;
Issue Name:
Add On Codes
Issue Number A000012009
Issue
Description:
Claims overpaid for add-on codes when the required primary procedure
either was not billed or was not paid for other reasons. Therefore, an issue
may exist when these codes are billed and reimbursed under Medicare Part
B in this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MD, NJ, NY, PA
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
IOM 100-04 Chapter 12, Section 30;
Issue Name:
Parenteral Nutrition Additives with Premix Solutions
Issue Number A000522010
Issue
Description:
When premix parenteral nutrition solutions are used there may not be
separate billing for the carbohydrates, amino acids or additives. Therefore,
an issue may exist when carbohydrates, amino acids, or additives are billed
and reimbursed under Medicare Part B in this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, PA
Providers
Affected:
DME Suppliers
Date Posted:
June 17, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
Article A37215; LCD L5063;
Issue Name: Manual Wheelchair Accessories Billed With Power Wheelchair Bases
Issue
Number
A000702010
Issue
Description:
A supplier can only supply those manual wheelchair options or accessories
that are defined with the code to be used with a manual wheelchair. When
supplying a power wheelchair, a provider may only supply those options or
accessories that are defined with the code to be used with a power
wheelchair. Therefore, an issue may exist when wheelchair options and
accessories are not billed and reimbursed under Medicare Part B in this
manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, MA, MD, NJ, NY, PA
Providers
Affected:
DME Suppliers
Date Posted: June 10, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
LCD L11473;
Issue Name:
Initial/Preparatory Knee Disarticulation Prosthesis
Issue
Number
A000692010
Issue
Description:
A potential issue may exist when an above knee initial prosthesis or an
above knee preparatory prosthesis is provided and certain prosthetic
substitutions and/or additions are billed at the same time. Therefore, an
issue may exist when these substitutions and/or additions are billed and
reimbursed under Medicare Part B in this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, MA, NY, PA
Providers
Affected:
DME Suppliers
Date Posted: June 10, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
LCD L11464;
Issue Name:
MS-DRG Validation for Liver Transplant (At this time, medical necessity is
excluded from review)
Issue
Number
A000502010
Issue
Description:
MS-DRG Validation 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 for MS-DRG 006; principal diagnosis, secondary diagnoses, and
procedures affecting or potentially affecting the MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: May 11, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual ( for dates of service on claim), ICD-9-CM
Addendums and Coding Clinics, PIM Chapter 6.5.3 Section A - C DRG
Validation Review, Uniform Hospital Discharge Data Set (UHDDS) Reporting of inpatient Data Elements, July 31, 1985, Federal Register (Vol.
50, No. 147), Pages 31038- 31040.;
Issue Name:
MS-DRG Validation for Heart Transplant (At this time, medical necessity is
excluded from review)
Issue
Number
A000512010
Issue
Description:
MS-DRG Validation 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 for MS-DRG 002; principal diagnosis, secondary diagnoses, and
procedures affecting or potentially affecting the MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: May 11, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual ( for dates of service on claim), ICD-9-CM
Addendums and Coding Clinics, PIM Chapter 6.5.3 Section A - C DRG
Validation Review, Uniform Hospital Discharge Data Set (UHDDS) Reporting of inpatient Data Elements, July 31, 1985, Federal Register (Vol.
50, No. 147), Pages 31038- 31040.;
Issue Name:
MS-DRG Validation for HIV (At this time, medical necessity is excluded from
review)
Issue
Number
A000422009
Issue
MS-DRG Validation requires that diagnostic and procedural information and
Description:
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 claims where diagnosis code 042 Human Immunodeficiency Virus
(HIV) Disease was billed as secondary. Principal diagnosis, secondary
diagnoses, and procedures affecting or potentially affecting the claim will be
reviewed for accuracy.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: May 11, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9 CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics, PIM Ch 6.5.3 A-C DRG Validation Review; UHDDS - Reporting of
Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 127),
Pages 31038- 31040.;
Issue Name:
IPPS Hospital to Hospital Transfers
Issue
Number
A000082009
Issue
Description:
Medicare pays full MS-DRG payments to the final discharging hospital, while
payment to the transferring hospital is often based upon a per diem rate
(depending on the length of stay). Therefore, an improperly reported transfer
may result in an overpayment when both hospitals receive full MS-DRG
payments.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: March 31, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
Section 1886(d) of the Social Security Act; Internet-Only Manual (IOM),
Publication100-04, Chapter 3, Sections 20.1.2.4 and 40.2.4,; Code of
Federal Regulations 42 CFR 412.4;
Issue Name:
MS-DRG Validation for Cardiac Procedures (At this time, medical necessity
is excluded from review)
Issue
Number
A000412009
Issue
Description:
DRG Validation 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 for MS-DRGs 228, 231, 233, 235, 237, 248, and 250, principal
diagnosis, secondary diagnosis, and procedures affecting or potentially
affecting the DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: March 23, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM
Addendums and Coding Clinics, PIM Ch 6.5.3, Section A-C, DRG Validation
Review, DRG Desk Reference Ingenix 2009. CodeWrite, April 2007; AHIMA;
Issue Name:
MS-DRG Validation for Major Large and Small Bowel Procedures (At this
time, medical necessity is excluded from review)
Issue
Number
A000402009
Issue
Description:
DRG Validation 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 for MS-DRGs 329, 330, and 331, principal diagnosis, secondary
diagnosis, and procedures affecting or potentially affecting the DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: March 23, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM
Addendums and Coding Clinics, PIM Ch 6.5.3, Section A-C, DRG Validation
Review, DRG Desk Reference Ingenix 2009. CodeWrite, April 2007;
AHIMA.;
Issue Name:
Intracranial Hemorrhage or Cerebral Infarction (At this time, medical
necessity validation limited to MS-DRG 069)
Issue
Number
A000432009
Issue
Description:
MS-DRG Validation 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 for MS-DRG 061, 062, 063, 064, 065, 066, 067, 068, 069 principal
diagnosis, secondary diagnosis, and procedures affecting or potentially
affecting the MS-DRG. Additionally, medical records for MS DRG 069 will be
reviewed for medical necessity as of September 9, 2010.
Type of
Review
DRG Coding and Medical Necessity Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: March 23, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM
Addendums and Coding Clinics, PIM Chapter 6.5.3 Section A - C DRG
Validation Review, UHDDS - Reporting of inpatient Data Elements, July 31,
1985, Federal Register (Vol. 50, No. 147), Pages 31038-31040. OIG Report
Validation of DRG 14 (MS-DRG 064, 065, 066), January 1988.;
Issue Name:
Oxygen Accessories
Issue
Number
A000332009
Issue
Description:
A potential issue may exist if certain oxygen accessories are billed when an
oxygen system rental has been billed in the month prior to the date of
service or in the subsequent month. Therefore, an issue may exist when
these accessories are billed and reimbursed under Medicare Part B in this
manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
NJ, PA
Providers
Affected:
DME Suppliers
Date Posted: February 10, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
LCD L11468; LCD Policy Article A33768;
Issue Name:
MS-DRG Validation for MS-DRG 189 Pulmonary Edema & Respiratory
Failure (At this time, Medical Necessity is excluded from review)
Issue
Number
A000352009
Issue
Description:
DRG Validation 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 for MS-DRG 189, principal diagnosis, secondary diagnosis, and
procedures affecting or potentially affecting the DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: January 19, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM
Addendums and Coding Clinics, PIM Ch 6.5.3, Section A - C - DRG
Validation Review, OIG Report DRG 87: Pulmonary Edema and Respiratory
Failure, August 1989;
Issue Name:
MS-DRG Validation for MS-DRGs for Tracheostomy (At this time, Medical
Necessity is excluded from review)
Issue
Number
A000362009
Issue
Description:
DRG Validation 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 for MS DRGs 003, 004, 011, 012, 013; principal diagnosis,
secondary diagnosis, and procedures affecting or potentially affecting the
DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: January 19, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM
Addendums and Coding Clinics, PIM Ch 6.5.3 A-C DRG Validation Review;
UHDDS - Reporting of Inpatient Data Elements, July 31, 1985, Federal
Register (Vol. 50, No. 147), Pages 31038-31040;
Issue Name:
MS-DRG Validation for MS-DRGs with Ventilator Support of 96+ Hours (At
this time, Medical Necessity is excluded from review)
Issue
Number
A000302009
Issue
Description:
DRG Validation 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 for MS DRGs 003, 004, 207, 870, 927 and 933; principal diagnosis,
secondary diagnosis, and procedures affecting or potentially affecting the
DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: January 19, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM
Addendums and Coding Clinics, PIM Ch 6.5.3, Section A - C - DRG
Validation Review, DRG Desk Reference Ingenix 2009. CodeWrite, April
2007; AHIMA;
Issue Name: Ambulance Unbundled Services During an Inpatient Hospital Stay
Issue
Number
A000062009
Issue
Description:
Ambulance services should be billed to the inpatient provider for services for
inpatients. Therefore, an issue may exist when a beneficiary received
ambulance services during an inpatient stay, which have been billed and
reimbursed under Medicare Part B.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Ambulance Providers
Date Posted: January 7, 2010
Dates of
Service:
Rolling 36 month review look back
Issue
References
Internet Only Manual, Medicare Benefit Policy Manual Publication 100-02
Chapter 10, Section 10 and 10.3.3; Internet Only Manual, Medicare
Processing Manual, Publication 100-04, Chapter 3, Sections 10.4 and 10.5.;
Internet Only Manual, Medicare Claims Processing Manual, Publication 10004, Chapter 15, Section 10.2, Summary of Benefit and 30.A, Modifier specific
to Ambulance Services.;
Issue Name:
Solid Insert with Seat or Back Wheelchair Cushions
Issue Number A000262009
Issue
Description:
Code E0992 (solid seat insert) is not separately payable when provided with
a seat or a seat back wheelchair cushion. Therefore an issue may exist
when E0992 is billed and reimbursed under Medicare Part B with a seat or
seat back wheelchair cushion.
Type of
Review
Automated Review for Overpayments
State(s)
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
Affected:
DME Suppliers
Date Posted:
December 22, 2009
Dates of
Service:
Rolling 36 month review look back
Issue
References
LCD Policy Article A17918;
Issue Name:
Lower Limb Suction Valve Prosthesis
Issue
Number
A000252009
Issue
Description:
Codes L5647 and L5652 describe a modification to a prosthetic socket that
incorporates a suction valve in the design. The items described by these
codes are not components of a suspension locking mechanism (L5671).
Therefore, an issue may exist when such a locking mechanism is billed and
reimbursed under Medicare Part B along with a suction valve suspension.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, NH, NJ, NY, PA, RI
Providers
Affected:
DME Suppliers
Date Posted: December 22, 2009
Dates of
Service:
Rolling 36 month review look back
Issue
References
LCD Policy Article A25310; Region A DMERC PSC Bulletin;
Issue Name: Prosthetic Additions with Initial or Preparatory Knee Prosthesis
Issue
Number
A000282009
Issue
Description:
When an initial below knee prosthesis (L5500) or a preparatory below knee
prosthesis (L5510-L5530, L5540) is provided, prosthetic substitutions and/or
additions of procedures and components are covered in accordance with the
functional level assessment, except for certain codes. Therefore, an issue
may exist when these codes are billed and reimbursed under Medicare Part
B with such a prosthesis.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NJ, NY, PA
Providers
Affected:
DME Suppliers
Date Posted: December 22, 2009
Dates of
Service:
Rolling 36 month review look back
Issue
References
LCD Policy L11464;
Issue Name:
Multiple DME Rentals within a Month
Issue
Number
A000042009
Issue
Description:
Certain procedure codes may not be billed in conjunction with other
procedure codes for the same date of service and for the same beneficiary.
Therefore an issue may exist when these codes are billed and reimbursed
under Medicare Part B on the same date of service and for the same
beneficiary.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
DME Suppliers
Date Posted: December 22, 2009
Dates of
Service:
Rolling 36 month review look back
Issue
References
CMS Pub.100-4, Ch 20, § 30.1, 30.2, 30.5, 30.7, 13.8; Social Security Act,
Volume I, Title XVIII, Section 1834;
Issue Name:
Headrest with a Power Operated Vehicle or a Power Wheelchair with a
Captain's Chair Seat
Issue
Number
A000272009
Issue
Description:
Headrests (E0955) may not be billed on the same date of service as a Power
Operated Vehicle (POV) or Power Wheelchair (PWC) with a captain's chair
seat. Therefore, an issue may exist when a beneficiary receives a Power
Operated Vehicle (POV) or Power Wheelchair (PWC) with a captain's chair
seat and a headrest, which has been billed and reimbursed under Medicare
Part B, on the same date of service.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
DE, MA, MD, ME, NH, NJ, NY, PA
Providers
Affected:
DME Suppliers
Date Posted: December 22, 2009
Dates of
Service:
Rolling 36 month review look back
Issue
References
LCD Policy L15845;
Issue Name:
Wheel Attachment with New Non-Wheeled Walker
Issue
Number
A000292009
Issue
Description:
Wheel attachment (E0155) cannot be paid on the same day or within one
month of the initial issue of a nonwheeled walker. Therefore, an issue may
exist when a beneficiary receives this wheel attachment, which has been
billed and reimbursed under Medicare Part B, within a month of an initial
issue of a nonwheeled walker.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
DME Suppliers
Date Posted: December 22, 2009
Dates of
Service:
Rolling 36 month review look back
Issue
References
LCD Policy L11472;
Issue Name: Clinical Social Worker during Inpatient Hospital
Issue
Number
A000222009
Issue
Description:
CSW services rendered during an inpatient acute care or skilled nursing
facility stay are not separately payable under Medicare Part B, instead they
are included in the facility’s Prospective Payment System (PPS) payment.
CSW providers are expected to render services under arrangement with the
facility. Therefore, an issue may exist when a beneficiary received CSW
services during an inpatient stay, which have been billed and reimbursed
under Medicare Part B.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
CSW Providers
Date Posted: December 11, 2009
Dates of
Service:
Rolling 36 month review look back
Issue
References
Medicare Benefit Policy Manual: Pub100-2, Ch15, § 170; CMS MedLearn
Matters Article #: SE0439.;
Issue Name: Pharmacy Supply and Dispensing Fees
Issue
Number
A000052009
Issue
Description:
Pharmacy supply and dispensing fees when billed by a DME supplier are
required to be accompanied with an oral anti-cancer, oral anti-emetic,
immunosuppressive drug or inhalation drug. The absence of one of the
aforementioned drugs billed on the same date of service or a denial of one of
the aforementioned drugs represents a potential issue.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, MA, ME, NH, NJ, NY, VT
Providers
Affected:
DME Suppliers
Date Posted: September 18, 2009
Dates of
Service:
Rolling 36 month review look back
Issue
References
Internet Only Manual 100-04 (Medicare Claims Processing Manual), Chapter
17 (Drugs and Biologicals), Section 80.7; Transmittal 754, Change Request
3990, Requirement 3990.15.; DME MAC Jurisdiction A Article for Nebulizers
A24944 (LCD L11499); DME MAC Jurisdiction A Article for Oral Anticancer
Drugs A25227 (LCD L5057); DME MAC Jurisdiction A Article for Oral
Antiemetic Drugs A25228 (LCD L5058); DME MAC Jurisdiction A Article for
Immunosuppressive Drugs A23662 (LCD L11531);
Issue Name:
Wheelchair Bundling
Issue Number
A000202009
Issue
Description:
A potential issue may exist if certain procedure codes are billed in
conjunction with other procedure codes for the same date of service and
the same beneficiary.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
DME Suppliers
Date Posted:
September 18, 2009
Dates of
Service:
Rolling 36 month review look back
Issue
References
LCD L11473, CMS Pub.100-3, Ch1, § 280.1 & 280.3;
Issue Name:
Urological Bundling
Issue Number A000192009
Issue
Description:
A potential issue may exist if certain urological procedure codes are billed
in conjunction with other urological procedure codes for the same date of
service and same beneficiary.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
DME Suppliers
Date Posted:
September 18, 2009
Dates of
Service:
Rolling 36 month review look back
Issue
References
CMS Pub.100-3, Ch1, § 230.17; LCD L5080; LCD Policy Article 25230;