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CMS Approved Audit Issues
This list includes all CMS-approved audit issues:
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| Issue Name: | Date of Death- DME | | Description: | Medicare does not pay for services or equipment after the beneficiary's date of death.
Provider Type Affected: DME by Supplier | | Date of Service: | 10/01/2007 - Open | | States Affected: | DME Issues: Suppliers who bill CIGNA Government Services | | Additional Information: | |
| | Issue Name: | Duplicate Claims - Physician (Carrier) | | Description: | Exact duplicate data fields submitted for physician (carrier) claims for the same service, same member, and same date of service (not including interim billing or corrected claims) resulting in duplicate payments.
Provider Type Affected: Physician (Carrier) | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: | Additional information can be found in the following manuals/publications:
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| | Issue Name: | Medical Necessity: Kidney and UTI | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 689. 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.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Medical Necessity: Other Digestive System Diagnosis | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 393. 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.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: | |
| | Issue Name: | Medical Necessity: Other Vascular Procedures | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 253 and 254. 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.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Medical Necessity: Percutaneous Cardiac Procedures | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 249. 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.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Medical Necessity: Renal Failure | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 682, 683 and 684. 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.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Medical Necessity: Syncope and Collapse | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 312. 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.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: | |
| | Issue Name: | Medical Necessity: Red Blood Cell Disorder | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 811. 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.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Medical Necessity: TIA | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 069. 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.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Medical Necessity: Chest Pain | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 313. 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.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Medical Necessity: Heart Failure and Shock | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 291, 292 and 293. 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.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Medical Necessity: Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders with MCC | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 391. 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.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Medical Necessity: COPD | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 190, 191 and 192. 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.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Medical Necessity: Nutritional and Misc Metabolic Disorders | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 640. 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.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Medical Necessity: Circulatory System Disorders | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 314, 315 and 316. 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.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Medical Necessity: Degenerative Nervous System Disorders | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 056 and 057. 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.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Medical Necessity: Atherosclerosis | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 302. 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.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Medical Necessity: Cardiac Arrhythmia | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 308. 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.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: | |
| | Issue Name: | Medical Necessity: Medical Back Problems | | Description: | RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 551 and 552. 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.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Other Vascular Procedures without CC/MCC: MS-DRG 254 | | 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 254, previously DRG 479, 553 and 554, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Other Circulatory System Diagnoses W MCC: MS-DRG 314 | | 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 314, previously DRG 144, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS-DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3 coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Cardiovascular Diseases (At this time Medical Necessity excluded from review for DRG(s) 280, 281, 282, 283, 284, 285, 288, 289, 290, 296, 297, 298, 299, 300, 301, 303, 304, 305, 306, 307, 309, 310 and 311) | | Description: | DRG Validation requires that diagnostic and procedural information and the discharge status of 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 280, 281, 282, 283, 284, 285, 288, 289, 290, 292, 293, 296, 297, 298, 299, 300, 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 311, 313, 316, previously DRGs 121, 122, 123, 126, 127, 129, 130, 131, 132, 133, 134, 135, 136, 137, 138, 139, 140, 143, 144, 145, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRGs.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1,2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Sections A-C DRG Validation Review
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| | Issue Name: | Fulvestrant - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) | | Description: | Each HCPCS unit of fulvestrant represents 25mg. Each 25mg of a dose must be billed with one HCPCS unit per patient, per date of service.
Provider Type Affected: Physician (Carrier) | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Palonosetron - Dose vs. Units Billed - Underpayment (At this time, Medical Necessity will be excluded from this review) | | Description: | Palonosetron (J2469) represents 25 micrograms (mcg) per unit and should be billed one (1) unit for every 25 mcg per patient.
Provider Type Affected: Physician (Carrier) | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Minor Bladder Procedures with MCC: MS-DRG 662 (At this time, Medical Necessity excluded from review) | | 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 662, previously DRG 308 and 309, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
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| | Issue Name: | Minor Bladder Procedures without CC/MCC: MS-DRG 664 (At this time, Medical Necessity excluded from review) | | 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 664, previously DRG 308 and 309, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
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| | Issue Name: | Filgrastim (480 mcg) - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) | | Description: | Filgrastim (J1441) represents 480 micrograms (mcg) per unit and should be billed 1 unit for every 480 mcg per patient, per date of service.
Provider Type Affected: Physician (Carrier)
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Dolasetron - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) | | Description: | Dolasetron (J1260) represents 10 milligrams (mg) per unit and should be billed one (1) unit for every 10 mg per patient.
Provider Type Affected: Physician (Carrier)
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Ambulance/transport services provided during an inpatient hospitalization | | Description: | Ambulance transports provided by hospital-based ambulance suppliers to beneficiaries who are in an inpatient stay are the responsibility of the inpatient hospital provider with the exception of transports on the day of admission, day of discharge and during a leave of absence from the inpatient facility.
Provider Type Affected: Lab/Ambulance
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Rituximab - Dose vs. Units Billed (At this time Medical Necessity will be excluded from this review) | | Description: | Rituximab (J9310) should be billed one (1) unit for every 100 mg per patient.
Provider Type Affected: Physician (Carrier)
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Leuprolide Acetate (for depot suspension): Dose vs. Units Billed (At this time Medical Necessity will be excluded from this review) | | Description: | Each HCPCS unit of leuprolide represents 7.5mg. A 7.5 mg. injection (1 month formulation) must be billed with 1 unit per patient per date of service, a 22.5 mg. injection (3 month formulation) must be billed with 3 units per patient per date of service, 30 mg. injection (4 month formulation) must be billed with 4 units per patient per date of service and a 45 mg. injection (6 month formulation) must be billed with 6 units per patient per date of service.
Provider Type Affected: Physician (Carrier)
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Paclitaxel - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) | | Description: | Paclitaxel (J9265) represents 30 mg per unit and should be billed at 1 unit for every 30 mg per patient, per date of service.
Provider Type Affected: Physician (Carrier)
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Cetuximab - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) | | Description: | Cetuximab (J9055) represents 10 mg per unit and should be billed one (1) unit for every 10 mg per patient.
Provider Type Affected: Physician (Carrier) | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Paclitaxel protein-bound particles - Dose vs. Units Billed (At this time Medical Necessity will be excluded from this review) | | Description: | Paclitaxel protein-bound particles (J9264) represents 1 mg per unit and should be billed at 1 unit for every 1 mg per patient, per date of service.
Provider Type Affected: Physician (Carrier) | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Disorders of Pancreas Except Malignancy without CC/MCC: MS-DRG 440 (At this time Medical Necessity excluded from review) | | 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 440, previously DRG 204, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
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| | Issue Name: | Endocrine, Nutritional & Metabolic Disorders (At this time Medical Necessity excluded from review for DRG(s) 637, 638, 639, 641, 642, 643, 644 and 645) | | 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 637, 638, 639, 640, 641, 642, 643, 644, 645, previously DRGs 294, 295, 296, 297, 298, 299, 300, 301, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRGs.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1,2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch 6.5.3, Sections A-C DRG Validation Review |
| | Issue Name: | Tenecteplase - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) | | Description: | Tenecteplase (J3100) represents 50 mg per unit and should be billed 1 unit for every 50 mg per patient, per date of service.
Provider Type Affected: Outpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Pamidronate Disodium - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) | | Description: | Pamidronate Disodium (J2430) represents 30 mg per unit. Providers are billing for units representing the milligrams, not the correct unit of one (1) unit for every 30 mg administered.
Provider Type Affected: Outpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Adenosine - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) | | Description: | Adenosine represents 6 mg per unit and should be billed at 1 unit for every 6 mg per patient per date of service.
Provider Type Affected: Outpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Zoledronic acid (Reclast), 1 mg - Dose vs. Units Billed - Overpayment (At this time, Medical Necessity will be excluded from this review) | | Description: | Zoledronic acid, (Reclast) represents 1mg per unit and should be billed one (1) unit for every 1 mg per patient.
Provider Type Affected: Outpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Inpatient Admissions without a Physician's Inpatient Admit Order | | Description: | Admissions to the inpatient setting require a physician's order in order to qualify and be paid as an inpatient stay.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) 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
2) Benefit Policy Manual Chapter 1 Section 10
3) Claims Processing Manual Chapter 3 Section 10 and 40.2.2
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| | Issue Name: | Percutaneous Cardiovascular Procedure with Drug-Eluting Stent without MCC: MS-DRG 247 (At this time, Medical Necessity excluded from review) | | 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 247, previously DRG 557 and 558, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Zoledronic acid, (Zometa) - Dose vs. Units Billed - Overpayment (At this time, Medical Necessity will be excluded from this review) | | Description: | Zoledronic acid, (Zometa) represents 1mg per unit and should be billed one (1) unit for every 1mg per patient. Claims for J3487 should be submitted so that the billed units represent the administered units, not the total number of milligrams. Zometa is given as a single 4mg injection and the number of units billed on a claim should be 4.
Provider Type Affected: Outpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Lymphoma and Nonacute Leukemia with MCC: MS-DRG 840 (At this time, Medical Necessity excluded from review) | | 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 840, previously DRG 403, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
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| | Issue Name: | DME vs. Inpatient | | Description: | DME claims should not be billed during an inpatient stay with the exception of: All L codes and codes that are within 2 days of discharge.
Provider Type Affected: DME by Supplier
| | Date of Service: | 10/01/2007 - Open | | States Affected: | DME Issues: Suppliers who bill CIGNA Government Services | | Additional Information: |
Additional information can be found in the following manuals/publications:
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| | Issue Name: | Cardiac Procedures (At this time Medical Necessity excluded from review) | | 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 034, 035, 036, 215, 223, 224, 225, 231, 232, 286, previously DRGs 577, 525, 535, 536, 106, 124, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM-Vol. 1,2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Sections A-C DRG Validation Review |
| | Issue Name: | Osteomyelitis without CC/MCC: MS-DRG 541 (At this time, Medical Necessity excluded from review) | | 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 541, previously DRG 238, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Other O.R. Procedures of the Blood and Blood-Forming Organs with MCC: MS-DRG 802 (At this time, Medical Necessity excluded from review) | | 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 802, previously DRG 394, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with CC: MS-DRG 623 (At this time, Medical Necessity excluded from review) | | 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 623, previously DRG 287, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Stomach, Esophageal and Duodenal Procedures without CC/MCC: MS-DRG 328 (At this time, Medical Necessity excluded from review) | | 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 claims, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 328, previously DRG 155, 156, 567 and 568, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
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| | Issue Name: | Bone Marrow Transplant: MS-DRG 009 (At this time, Medical Necessity excluded from review) | | 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 claims, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 009, previously DRG 481, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Stomach, Esophageal and Duodenal Procedures with MCC: MS-DRG 326 (At this time, Medical Necessity excluded from review) | | 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 326, previously DRG 155, 156, 567 and 568, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
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| | Issue Name: | Kidney and Ureter Procedures for Non-Neoplasm with MCC: MS-DRG 659 (At this time, Medical Necessity excluded from review) | | 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 659, previously DRG 304 and 305, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Major Bladder Procedure with MCC: MS-DRG 653 (At this time, Medical Necessity excluded from review) | | 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 653, previously DRG 573 principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Cardiac Pacemaker Device Replacement with MCC: MS-DRG 258 (At this time, Medical Necessity excluded from review) | | 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 258, previously DRG 118, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Lymphoma and Nonacute Leukemia with CC: MS-DRG 841 (At this time, Medical Necessity excluded from review) | | 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 841, previously DRG 404, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Peripheral/Cranial Nerve and Other Nervous System Procedures with MCC: MS-DRG 040 (At this time, Medical Necessity excluded from review) | | 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 040, previously DRG 006, 007 and 008, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
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| | Issue Name: | Darbepoetin alfa (ESRD) - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) | | Description: | Darbepoetin alfa (ESRD) (J0882) represents 1 microgram (mcg) per unit and should be billed one (1) unit for every 1mcg per patient.
Provider Type Affected: Outpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
http://www.cms.hhs.gov/transmittals/downloads/R1669CP.pdf
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf
http://www.cms.hhs.gov/mlnmattersarticles/downloads/MM6323.pdf
http://www.cancerconsultants.com/druginserts/aranesp.pdf
http://www.cms.hhs.gov/transmittals/downloads/R1336CP.pdf |
| | Issue Name: | Irinotecan - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) | | Description: | Irinotecan (J9206) represents 20 mg per unit and should be billed one (1) unit for every 20 mg per patient. Claims for J9206 should be submitted so that the billed units represent the administered units, not the total number of milligrams.
Provider Type Affected: Outpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6323.pdf
http://www.cms.hhs.gov/transmittals/downloads/R1669CP.pdf
http://www.cancerconsultants.com/druginserts/Irinotecan.pdf
http://www.cms.hhs.gov/Transmittals/downloads/R1336CP.pdf |
| | Issue Name: | Docetaxel - Dose vs. Units (At this time, Medical Necessity will be excluded from this review) | | Description: | Docetaxel (J9170) represents 20 mg per unit and should be billed 1 unit for every 20 mg per patient.
Provider Type Affected: Outpatient Hospital
| | Date of Service: | 10/01/2007 - 12/31/2009 | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6323.pdf
http://www.cms.hhs.gov/transmittals/downloads/R1669CP.pdf
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf
http://products.sanofi-aventis.us/taxotere/taxotere.html |
| | Issue Name: | Carboplatin - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) | | Description: | Carboplatin (J9045) represents 50 mg per unit and should be billed one (1) unit for every 50 mg per patient.
Provider Type Affected: Outpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf
http://www.cms.hhs.gov/transmittals/downloads/R1669CP.pdf
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6323.pdf |
| | Issue Name: | Bevacizumab - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) | | Description: | Bevacizumab should be billed one (1) unit for every 10 milligrams ordered/administered per patient. Claims for J9035 should be submitted so that the billed units represent the administered units, not the total number of milligrams.
Provider Type Affected: Outpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6323.pdf
http://www.cms.hhs.gov/transmittals/downloads/R1669CP.pdf
http://www.gene.com/gene/products/information/pdf/avastin-prescribing.pdf
http://www.cms.hhs.gov/Transmittals/downloads/R1336CP.pdf |
| | Issue Name: | Darbepoetin alfa (non-ESRD) - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) | | Description: | Darbepoetin alfa (non-ESRD) (J0881) represents 1 microgram (mcg) per unit and should be billed one (1) unit for every 1 mcg per patient.
Provider Type Affected: Outpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
http://www.cms.hhs.gov/transmittals/downloads/R1669CP.pdf
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf
http://www.cms.hhs.gov/mlnmattersarticles/downloads/MM6323.pdf
http://www.cancerconsultants.com/druginserts/aranesp.pdf
http://www.cms.hhs.gov/transmittals/downloads/R1336CP.pdf
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| | Issue Name: | Respiratory Infections & Inflammations without CC/MCC: MS-DRG 179 (Medical Necessity is excluded from review at this time). | | 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 179, previously DRG 080, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS-DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3 coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Respiratory Infections & Inflammations with CC: MS -DRG 178 (Medical Necessity is excluded from review at this time) | | 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 178, previously DRG 079, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS-DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3 coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Respiratory Infections & Inflammations with MCC: MS-DRG 177 (Medical Necessity is excluded from review at this time) | | 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 177, previously DRG 079, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS-DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3 coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Splenectomy w MCC, w CC, w/o CC/MCC (At this time, Medical Necessity excluded from review) | | 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 799, 800, 801, previously DRG 392, 393, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1,2 &3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Sections A-C DRG Validation Review |
| | Issue Name: | Bilateral or Multiple Major Joint Procedures of Lower Extremity with MCC: MS-DRG 461 (At this time Medical Necessity excluded from review) | | 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 461, previously DRG 471, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Viral Meningitis without CC/MCC: MS-DRG 076 (At this time, Medical Necessity excluded from review) | | 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 076, previously DRG 021, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Lung Transplant: MS-DRG 007 (At this time, Medical Necessity excluded from review) | | 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 007, previously DRG 495, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis without MCC: MS-DRG 024 (At this time, Medical Necessity excluded from review) | | 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 024, previously DRG 543, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis with MCC or Chemo Implant: MS-DRG 023 (At this time, Medical Necessity excluded from review) | | 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 023, previously DRG 543, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Full Thickness Burn with Skin Graft or Inhalation Injury without CC/MCC: MS-DRG 929 (At this time Medical Necessity excluded from review) | | 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 929, previously DRG 506 and 507, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours with Skin Graft: MS-DRG 927 (At this time Medical Necessity excluded from review) | | 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 927, previously DRG 504, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with CC: MS-DRG 021 (At this time, Medical Necessity excluded from review) | | 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 021, previously DRG 528, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with MCC: MS-DRG 020 (At this time, Medical Necessity excluded from review) | | 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 claims, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 020, previously 528, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Tracheotomy for Face, Mouth, and Neck Diagnoses with CC MS-DRG 012 (At this time, Medical Necessity excluded from review) | | 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 claims, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 012, previously DRG 482, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Tracheotomy for Face, Mouth, and Neck Diagnoses with MCC: MS-DRG 011 (At this time, Medical Necessity excluded from review) | | 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 claims, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 011, previously DRG 482, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Kidney Transplant: MS-DRG 652 (At this time, Medical Necessity excluded from review) | | 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 652, previously DRG 302, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) PIM Ch. 6.5.3, Section A-C DRG Validation Review
3) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) |
| | Issue Name: | Rectal Resection with MCC: MS-DRG 332 (At this time, Medical Necessity excluded from review) | | 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 claims, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 332, previously 146 and 147, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Liver Transplant with MCC or Intestinal Transplant: MS-DRG 005 (At this time, Medical Necessity excluded from review) | | 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 005, previously DRG 480, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Heart Transplant or Implant of Heart Assist System with MCC - MS-DRG 001 (At this time, Medical Necessity excluded from review) | | 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 001, previously DRG 103, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | ECMO or Tracheotomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R.: MS-DRG 003 (At this time, Medical Necessity excluded from review) | | 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 003, previously DRG 541, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) PIM Ch. 6.5.3, Section A-C DRG Validation Review
3) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) |
| | Issue Name: | Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with CC: MS-DRG 217 (At this time, Medical Necessity excluded from review) | | 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 217, previously DRG 104, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Rectal Resection with CC: MS-DRG 333 (At this time, Medical Necessity excluded from review) | | 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 claims, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 333, previously DRG 146 and 147, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Stomach, Esophageal and Duodenal Procedures with CC: MS-DRG 327 (At this time, Medical Necessity excluded from review) | | 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 327, previously DRG 155, 156, 567 and 568, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Major Bladder Procedures with CC: MS-DRG 654 (At this time, Medical Necessity excluded from review) | | 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 654, previously DRG 573, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Peripheral/Cranial Nerve and Other Nervous System Procedures with CC or Peripheral Neurostimulator: MS-DRG 041 (At this time, Medical Necessity excluded from review) | | 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 041, previously DRG 006, 007 and 008, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Other Male Reproductive System O.R. Procedures except Malignancy with CC/MCC: MS-DRG 717 (At this time, Medical Necessity excluded from review) | | 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 717, previously DRG 345, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Other Kidney and Urinary Tract Procedures without CC/MCC: MS-DRG 675 (At this time, Medical Necessity excluded from review) | | 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 675, previously DRG 315, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders with MCC: MS-DRG 616 (At this time, Medical Necessity excluded from review) | | 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 616, previously DRG 285, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Other Hepatobiliary or Pancreas O.R. Procedures with CC: MS-DRG 424 (At this time, Medical Necessity excluded from review) | | 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 424, previously DRG 201, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Other Ear, Nose, Mouth and Throat O.R. Procedures with CC/MCC: MS-DRG 133 (At this time, Medical Necessity excluded from review) | | 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 133, previously DRG 052 and 055, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Other Digestive System O.R. Procedures without CC/MCC: MS-DRG 358 (At this time, Medical Necessity excluded from review) | | 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 358, previously DRG 170 and 171, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with CC: MS-DRG 577 (At this time Medical Necessity excluded from review) | | 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 577, previously DRG 265 and 266, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | O.R. Procedure with Diagnoses of Other Contact with Health Services without CC/MCC: MS-DRG 941 (At this time Medical Necessity excluded from review) | | 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 941, previously DRG 461, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009))
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Knee Procedures with Principal Diagnosis of Infection with CC: MS-DRG 486 (At this time, Medical Necessity excluded from review) | | 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 486, previously DRG's 501 & 502, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
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| | Issue Name: | Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Other O.R. Procedure with CC/MCC: MS-DRG 829 (At this time Medical Necessity excluded from review) | | 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 829, previously DRG 408, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders with CC: MS-DRG 617 (At this time Medical Necessity excluded from review) | | 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 617, previously DRG 285, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Other Circulatory System Diagnoses with CC: MS-DRG 315 | | 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 315, previously DRG's 144 and 145, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Lymphoma and Nonacute Leukemia with Other O.R. Procedure with MCC: MS-DRG 823 (At this time, Medical Necessity excluded from review) | | 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 823, previously DRG's 401 & 402, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Other O.R. Procedures of the Blood and Blood-Forming Organs with CC: MS-DRG 803 (At this time, Medical Necessity excluded from review) | | 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 803, previously DRG 394, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Other Female Reproductive System O.R. Procedures with CC/MCC: MS-DRG 749 (At this time, Medical Necessity excluded from review) | | 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 749, previously DRG 365, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Other Vascular Procedures with CC: MS-DRG 253 | | 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 253, previously DRG's 479, 553 & 554, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Percutaneous Cardiovascular Procedure with Drug-Eluting Stent with MCC or 4+ Vessels/Stents: MS-DRG 246 (At this time, Medical Necessity excluded from review) | | 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 246, previously DRG 557 and 558, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Permanent Cardiac Pacemaker Implant with CC: MS-DRG 243 (At this time, Medical Necessity excluded from review) | | 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 243, previously DRG 551 and 552, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Full Thickness Burn without Skin Graft or Inhalation Injury: MS-DRG 934 (At this time, Medical Necessity excluded from review) | | 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 934, previously DRG 508 and 509, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Amputation for Circulatory System Disorders Except Upper Limb and Toe with MCC: MS-DRG 239 (At this time, Medical Necessity excluded from review) | | 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 239, previously DRG 113, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours without Skin Graft: MS-DRG 933 (At this time, Medical Necessity excluded from review) | | 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 933, previously DRG 505, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | HIV with Extensive O.R. Procedure with MCC: MS-DRG 969 (At this time, Medical Necessity excluded from review) | | 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 969, previously DRG 488, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Major Cardiovascular Procedures with MCC or Thoracic Aortic Aneurysm Repair: MS-DRG 237 (At this time, Medical Necessity excluded from review) | | 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 237, previously DRG 110 and 111, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Cholecystectomy Except by Laparoscope without C.D.E. with CC: MS-DRG 415 (At this time, Medical Necessity excluded from review) | | 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 415, previously DRG 197 and 198, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Cardiac Defibrillator Implant without Cardiac Catheterization with MCC: MS-DRG 226 (At this time, Medical Necessity excluded from review) | | 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 226, previously DRG 515, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009)
2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009)
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Pulmonary Edema and Respiratory Failure: MS-DRG 189 (At this time, Medical Necessity excluded from review). | | 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, previously DRG 087, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Heart Failure and Shock with MCC: MS-DRG 291 | | 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 291, previously DRG 127, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Psychoses: MS-DRG 885 (At this time, Medical Necessity excluded from review). | | 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 885, previously DRG 430, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Major Joint Replacement or Reattachment of Lower Extremity without MCC: MS-DRG 470 (At this time, Medical Necessity excluded from review) | | 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 470, previously DRG 544, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Rehabilitation with CC/MCC: MS-DRG 945 (At this time, Medical Necessity excluded from review) | | 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 945, previously DRG 462, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Pneumothorax without CC/MCC: MS-DRG 201 (At this time, Medical Necessity excluded from review) | | 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 201, previously DRG's 094 and 095, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Cardiac Defibrillator Implant with Cardiac Catheterization with Acute Myocardial Infarction/Heart Failure/Shock with MCC: MS-DRG 222 (At this time, Medical Necessity excluded from review) | | 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 222, previously DRG 535, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Percutaneous Cardiovascular Procedure with Non Drug-Eluting Stent with MCC or 4+ Vessels/Stents: MS-DRG 248 (At this time, Medical Necessity excluded from review) | | 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 248, previously DRG 555 and 556, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Spinal Fusion Except Cervical without MCC: MS-DRG 460 (At this time, Medical Necessity excluded from review) | | 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 460, previously DRG 497 and 498, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with MCC: MS-DRG 216 (At this time, Medical Necessity excluded from review) | | 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 216, previously DRG 104, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Fractures of Femur with MCC: MS-DRG 533 (At this time, Medical Necessity excluded from review). | | 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 533, previously DRG 235, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Knee Procedures without Principal Diagnosis of Infection with CC/MCC: MS-DRG 488 (At this time, Medical Necessity excluded from review) | | 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 488, previously DRG 503, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Minor Small and Large Bowel Procedures with MCC: MS-DRG 344 (At this time, Medical Necessity excluded from review. | | 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 344, previously DRG 152 and 153, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Other O.R. Procedures for Multiple Significant Trauma with MCC: MS-DRG 957 (At this time, Medical Necessity excluded from review) | | 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 957, previously DRG 486, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Permanent Cardiac Pacemaker Implant with MCC: MS-DRG 242 (At this time, Medical Necessity excluded from review) | | 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 242, previously DRG 551 and 552, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Amputation for Circulatory System Disorders Except Upper Limb and Toe with CC: MS-DRG 240 (At this time, Medical Necessity excluded from review) | | 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 240, previously DRG 113, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Cardiac Defibrillator Implant without Cardiac Catheterization without MCC: MS-DRG 227 (At this time, Medical Necessity excluded from review) | | 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 227, previously DRG 515, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Extracranial Procedures with CC: MS-DRG 038 (At this time, Medical Necessity excluded from review) | | 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 038, previously DRG 533 and 534, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Respiratory System Diagnosis with Ventilator Support < 96 Hours: MS-DRG 208 (At this time, Medical Necessity excluded from review). | | 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 208, previously DRG 566, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Other Vascular Procedures with MCC: MS-DRG 252 (At this time, Medical Necessity excluded from review) | | 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 252, previously DRG 479, 553 and 554, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC: MS-DRG 574 (At this time Medical Necessity excluded from review) | | 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 574, previously DRG 263 and 264, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with MCC: MS-DRG 573 (At this time Medical Necessity excluded from review) | | 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 573, previously DRG 263 and 264, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders without CC/MCC: MS-DRG 465 (At this time Medical Necessity excluded from review) | | 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 465, previously DRG 217, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Other Digestive System O.R. Procedures with MCC: MS-DRG 356 (At this time, Medical Necessity excluded from review) | | 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 356, previously DRG 170 and 171, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with MCC: MS-DRG 622 (At this time, Medical Necessity excluded from review) | | 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 622, previously DRG 287, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: | Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Other Digestive System O.R. Procedures with CC: MS-DRG 357 (At this time, Medical Necessity excluded from review) | | 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 357, previously DRG 170 and 171, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: | Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Other Hepatobiliary or Pancreas O.R. Procedures with MCC: MS-DRG 423 (At this time, Medical Necessity excluded from review) | | 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 423, previously DRG 201, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis without CC/MCC: MS-DRG 578 (At this time Medical Necessity excluded from review) | | 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 578, previously DRG 265 and 266, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with MCC: MS-DRG 576 (At this time Medical Necessity excluded from review) | | 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 576, previously DRG 265 and 266, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Skin Graft and/or Debridement for Skin Ulcer or Cellulitis without CC/MCC: MS-DRG 575 (At this time, Medical Necessity excluded from review) | | 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 575, previously DRG 263 and 264, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with CC: MS-DRG 464 (At this time Medical Necessity excluded from review) | | 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 464, previously DRG 217, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with MCC: MS-DRG 463 (At this time, Medical Necessity excluded from review) | | 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 463, previously DRG 217, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | O.R. Procedure with Diagnoses of Other Contact with Health Services with CC: MS-DRG 940 (At this time Medical Necessity excluded from review) | | 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 940, previously DRG 461, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | O.R. Procedure with Diagnoses of Other Contact with Health Services with MCC: MS-DRG 939 (At this time Medical Necessity excluded from review) | | 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 939, previously DRG 461, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Other Circulatory System O.R. Procedures: MS-DRG 264 (At this time, Medical Necessity excluded from review) | | 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 264, previously DRG 120, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Cardiac Pacemaker Revision Except Device Replacement without CC/MCC: MS-DRG 262 (At this time, Medical Necessity excluded from review) | | 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 MS-DRG 262, previously DRG 117, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) PIM Ch. 6.5.3, Section A-C DRG Validation Review
3) ICD-9-CM Addendums and Coding Clinics
|
| | Issue Name: | Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC: MS-DRG 624 (At this time, Medical Necessity excluded from review) | | 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 624, previously DRG 287, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) PIM Ch. 6.5.3, Section A-C DRG Validation Review
3) ICD-9-CM Addendums and Coding Clinics
|
| | Issue Name: | Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260 (At this time, Medical Necessity excluded from review) | | 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 260, previously DRG 117, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256 (At this time, Medical Necessity excluded from review) | | 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 256, previously DRG 114, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673 (At this time Medical Necessity excluded from review) | | 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 673, previously DRG 315, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Wound Debridements for Injuries without CC/MCC: MS-DRG 903 (At this time Medical Necessity excluded from review) | | 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 903, previously DRG 440, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Wound Debridements for Injuries with MCC: MS-DRG 901 (At this time Medical Necessity excluded from review) | | 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 901, previously DRG 440, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Wound Debridements for Injuries with CC: MS-DRG 902 (At this time Medical Necessity excluded from review) | | 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 902, previously DRG 440, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Postoperative or Posttraumatic Infections with O.R. Procedure with MCC: MS-DRG 856 (At this time Medical Necessity excluded from review) | | 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 856, previously DRG 579, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Postoperative or Posttraumatic Infections with O.R. Procedure with CC: MS-DRG 857 (At this time, Medical Necessity excluded from review) | | 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 claims, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 857, previously DRG 579, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Infectious and Parasitic Diseases with O.R. Procedure with MCC: MS-DRG 853 (At this time, Medical Necessity excluded from review) | | 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 853, previously DRG 578, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Postoperative or Posttraumatic Infections with O.R. Procedure without CC/MCC: MS-DRG 858 (At this time Medical Necessity excluded from review) | | 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 858, previously DRG 579, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Infectious and Parasitic Diseases with O.R. Procedure with CC: MS-DRG 854 (At this time Medical Necessity excluded from review) | | 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 854, previously DRG 578, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
| | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Infectious and Parasitic Diseases with O.R. Procedure without CC/MCC: MS-DRG 855 (At this time Medical Necessity excluded from review) | | 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 855, previously DRG 578, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | O.R. Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876 (At this time Medical Necessity excluded from review) | | 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 876, previously DRG 424, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928 (At this time Medical Necessity excluded from review) | | 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 928, previously DRG 506 and 507, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674 (At this time Medical Necessity excluded from review) | | 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 674, previously DRG 315, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Nonextensive Burns: MS-DRG 935 (At this time Medical Necessity excluded from review) | | 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 935, previously DRG 510 and 511, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: | Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Peritoneal Adhesiolysis with MCC: MS-DRG 335 (At this time, Medical Necessity excluded from review) | | 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 335, previously DRG 150 and 151, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
1) ICD-9-CM Addendums and Coding Clinics
2) ICD-9-CM Vol. 1, 2 & 3, coding manuals
3) PIM Ch 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Barium Swallow Studies Units Billed | | Description: | Barium Swallow Studies can only be billed with a unit of (1) per patient per date of service.
Provider Type Affected: Physician (Carrier) / Outpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
|
| | Issue Name: | Adenosine - Dose vs. Units billed | | Description: | Adenosine represents 30 mg per unit and should be billed 1 unit for every 30 mg per patient per date of service.
Provider Type Affected: Outpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
|
| | Issue Name: | Nebulizer, Demonstration and Evaluation Units Billed | | Description: | Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPS device can only be reported as one unit per day of service per patient.
Provider Type Affected: Outpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
|
| | Issue Name: | Q4099 Formoterol fumarate (perforomist) | | Description: | By description HCPCS Code Q4099 represents 20 micrograms. Patients are allowed a maximum of two vials of formoterol (20 micrograms each) per day.
Provider Type Affected: DME | | Date of Service: | | | States Affected: | Suppliers who bill CIGNA Government Services | | Additional Information: |
Additional information can be found in the following manuals/publications:
Paid date: 10/01/2007 - Open |
| | Issue Name: | J7605 Arformoterol, (Brovana) | | Description: | By definition Arformoterol, (Brovana) represents 15 micrograms. Patients are allowed a maximum of two vials of arformoterol (15 micrograms) per day.
Provider Type Affected: DME | | Date of Service: | | | States Affected: | Suppliers who bill CIGNA Government Services | | Additional Information: |
Additional information can be found in the following manuals/publications:
Paid date: 10/01/2007 - Open |
| | Issue Name: | Budesonide - Dose vs.Billed Units | | Description: | Budesonide should be billed one unit of service for each vial dispensed regardless of vial dose for a maximum of 62 units per month.
Provider Type Affected: DME | | Date of Service: | | | States Affected: | Suppliers who bill CIGNA Government Services | | Additional Information: |
Additional information can be found in the following manuals/publications:
Paid date: 10/01/2007 - Open |
| | Issue Name: | Failure to Correctly Bill Codes on the Medically Unlikely Edit List | | Description: | Certain codes on the MUE list are being incorrectly billed. An error was made in billing these codes, because more units were billed for same date of service for the same beneficiary by the same provider than what is medically likely and an appropriate modifier was not appended to the claim line.
Provider Type Affected: Outpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage
http://www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/MUE_Prov_Sup_PUB_LTR_9_2008.pdf
https://www.cahabagba.com/part_b/education_and_outreach/newsletters/2007/july/July2007NL.pdf |
| | Issue Name: | Upper Limb and Toe Amputation for Circulatory System Disorders with MCC: MS-DRG 255 (At this time, Medical Necessity excluded from review). | | 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 255, previously DRG 114 principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Cirrhosis and Alcoholic Hepatitis with MCC: MS- DRG 432 (At this time, Medical Necessity excluded from review). | | 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 432, previously DRG 202, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Septicemia without Mechanical Ventilation 96+ Hours without MCC: MS-DRG 872 (At this time, Medical Necessity excluded from review). | | 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 872, previously DRG 576, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Nonextensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC - MS-DRG 989 (At this time, Medical Necessity excluded from review). | | 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 989, previously DRG 477, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987 (At this time, Medical Necessity excluded from review). | | 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 987, previously DRG 477, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Other Respiratory System O.R. Procedures without CC/MCC: MS-DRG 168 (At this time, Medical Necessity excluded from review). | | 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 168, previously DRG 076/077, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Extensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983 (At this time, Medical Necessity excluded from review). | | 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 983, previously DRG 468, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Other Respiratory System O.R. Procedures with CC: MS-DRG 167 (At this time, Medical Necessity excluded from review). | | 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 167, previously DRG 076, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Other Digestive System Diagnoses with CC: MS-DRG 394 (At this time, Medical Necessity excluded from review). | | 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 394, previously DRG 188, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Inflammatory Bowel Disease with CC: MS-DRG 386 (At this time, Medical Necessity excluded from review). | | 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 386, previously DRG 179, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Major Gastrointestinal Disorders and Peritoneal Infections with CC: MS-DRG 372 (At this time, Medical Necessity excluded from review). | | 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 372, previously DRG 572, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review
|
| | Issue Name: | Other Respiratory System O.R. Procedures with MCC: MS-DRG 166 (At this time, Medical Necessity excluded from review). | | 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 166, previously DRG 076, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Major Small and Large Bowel Procedures without CC/MCC: MS-DRG 331 (At this time, Medical Necessity excluded from review). | | 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 331, previously DRG 570, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found on the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Major Small and Large Bowel Procedures with CC: MS-DRG 330 (At this time, Medical Necessity excluded from review). | | 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 330, previously DRG 569, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found on the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Major Small and Large Bowel Procedures with MCC: MS- DRG 329 (At this time, Medical Necessity excluded from review). | | 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 329, previously DRG 149, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found on the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Major Chest Procedures without CC/MCC: MS-DRG 165 (At this time, Medical Necessity excluded from review). | | 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 165, previously DRG 075, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found on the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Major Chest Procedures with MCC: MS-DRG 163 (At this time, Medical Necessity excluded from review). | | 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 163, previously DRG 075, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found on the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Major Chest Procedures with CC: MS-DRG 164 (At this time, Medical Necessity excluded from review). | | 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 164, previously DRG 075, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found on the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207 (At this time, Medical Necessity excluded from review). | | Description: | DRG Validation requires that diagnostic and procedural information and the 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 207, previously DRG 565, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found on the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Septicemia without Mechanical Ventilation 96+ Hours with MCC: MS-DRG 871 (At this time, Medical Necessity excluded from review). | | 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 871, previously DRG 576, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found on the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981 (At this time, Medical Necessity excluded from review). | | 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 981, previously DRG 468, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found on the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Extensive O.R. Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982 (At this time, Medical Necessity excluded from review). | | 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 982, previously DRG 468, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found on the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with CC - MS-DRG 988 (At this time, Medical Necessity excluded from review). | | 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 988, previously DRG 477, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found on the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Coagulation Disorders: MS-DRG 813 (At this time, Medical Necessity excluded from review). | | 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 813, previously DRG 397, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found on the following manuals/publications:
ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H
ICD-9-CM Addendums and Coding Clinics
PIM Ch. 6.5.3, Section A-C DRG Validation Review |
| | Issue Name: | Wheelchair Bundling | | Description: | Bundling guidelines for wheelchair bases and options/accessories indicate certain procedure codes are part of other procedure codes and, as a result, are not separately payable.
Provider Type Affected: DME | | Date of Service: | | | States Affected: | Suppliers who bill CIGNA Government Services | | Additional Information: |
Additional information can be found in the following manuals/publications:
Search by the above listed “Issue Name”
Paid date: 10/01/2007 - Open |
| | Issue Name: | Urological Bundling | | Description: | Certain procedure codes are part of other procedure codes and are not separately payable.
Provider Type Affected: DME | | Date of Service: | | | States Affected: | Suppliers who bill CIGNA Government Services | | Additional Information: |
Additional information can be found in the following manuals/publications:
Search by the above listed “Issue Name”
Paid date: 10/01/2007 - Open |
| | Issue Name: | Clinical Social Worker (CSW) Services | | Description: | Clinical Social Worker (CSW) services rendered during an Inpatient Hospital stay are not separately payable under Medicare Part B; they are included in the facility’s Prospective Payment System (PPS) payment. CSW providers are expected to seek reimbursement from the facility.
Provider Types Affected: CSW Providers | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
Medicare Benefit Policy Manual: Pub 100-02, Ch 15, § 170
CMS Med Learn Matters Article #: SE0439
Search by the above listed “Issue Name” |
| | Issue Name: | Blood Transfusions | | Description: | CPT codes 36430, 36440, 36450, and 36455 (excluding claims with any modifiers) should be billed as one (1) per session, regardless of the number of units transfused on that date of service.
Provider Types Affected: Outpatient Hospital and Physician | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
Federal Register, Volume 67, No.212, 66868
Program Memorandum Intermediaries, Transmittal A-01-50, April 12, 2001, page 1
CMS Pub 100-04, Ch. 4, § 231.8 |
| | Issue Name: | Untimed Codes | | Description: | CPT Codes (excluding modifiers KX, and 59) where the procedure is not defined by a specific timeframe (untimed codes), the provider should enter a one (1) in the units billed column per date of service.
Provider Types Affected: Outpatient Hospital and Physician | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
CMS Pub 100-04, Transmittal 1019, dated 8.3.06, pages 7-11
CMS Pub 100-04, Ch. 5, § 20.2
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| | Issue Name: | IV Hydration Therapy | | Description: | Based on the definition of CPT 90760 (excluding claims modifier-59 ), the maximum number of units should be one (1) per patient per date of service. Beginning 1.1.09, code 90760 was replaced with code 96360.
Provider Types Affected: Outpatient Hospital and Physician. | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found in the following manuals/publications:
CMS Pub 100-4 Ch. 12, pages 31-32
CMS Pub 100-20, Transmittal 419, page 7
MLN Matters, MM6349 R/T RC Release Date 12.19.08, page 4 |
| | Issue Name: | Bronchoscopy Services | | Description: | CPT Codes 31625, 31628 and 31629 should be billed with a maximum number of units of one (1) per patient per date of service (excluding claims with modifier 59) should only be reported with one unit per date of service.
Provider Types Affected: Outpatient Hospital and Physician. | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found on the following website(s):
http://www.thoracic.org American Medical Association's (AMA) Current Procedural Terminology (CPT) for 2007, 2008 and 2009. |
| | Issue Name: | Once in a lifetime procedures | | Description: | By virtue of the description of the CPT code, these codes can be performed only once per patient lifetime. Claims with modifier-58 will be excluded from your audit with dates of service starting 1/1/09. Starting 1/1/09 this code was allowed to be billed more than once if the provider used the modifier.
Provider Types Affected: Outpatient Hospital and Physician. | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found on the following manuals/publications:
American Medical Association's (AMA) Current Procedural Terminology (CPT) for 2007, 2008 and 2009 |
| | Issue Name: | Pediatric codes exceeding age parameters | | Description: | Newborn/Pediatric CPT codes being applied/billed for patients which exceed the age limit defined by the CPT code.
Provider Types Affected: Outpatient Hospital and Physician. | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: |
Additional information can be found on the following manual/publication:
American Medical Association's (AMA) Current Procedural Terminology (CPT) for 2007, 2008 and 2009
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| | Issue Name: | J2505: Injection, Pegfilgrastim, 6 mg. | | Description: | Claims for J2505 should be submitted so that the units billed represent the number of multiples of 6mg administered, not the total number of mgs.
Provider Types Affected: Outpatient Hospital and Physician. | | Date of Service: | 10/01/2007 - Open | | States Affected: | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia | | Additional Information: | Additional information can be found in the following manuals/publications:
CMS Manual System, Publication 100-04 Medicare Processing Manual, Transmittal 949 (dated May 12, 2006
MLN Matters Number MM5912, Release Date: January 18, 2008
MLN Matters Number MM4380, Release Date: May 12, 2006
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