Updated on: January 31, 2013

Connolly DME Issue Follows OIG Report

By
Original story posted on: January 6, 2012

alert-powered-by-decision-health

 

 

 

 

 

 

 

Connolly, the Region C recovery auditor, posted a durable medical equipment issue that could prove lucrative, if an Office of Inspector General report on the topic is any indication.

The RAC will look for incorrect payments for maintenance and servicing of capped rental DME, according to the issue approved Dec. 23. Payment for maintenance and service of that equipment "is included in the rental payments and should not be reimbursed separately," Connolly stated on its website.

In an August 2010 report, "A Review of Claims for Capped Rental Durable Medical Equipment," OIG found that from 2006 to 2008, Medicare "erroneously allowed" $2.2 million in payments on 31,939 claims for maintenance and service of beneficiary-rented equipment.

OIG also discovered that Medicare erroneously allowed almost $4.4 million for repairs for beneficiary-rented capped rental DME and almost $27 million for repair claims of beneficiary-owned DME that did not meet payment requirements, the report stated.

DME is certainly a provider type that has seen increased scrutiny and enforcement. Here are a few examples of DME fraud:

  • The former owner of a Houston DME company was sentenced in December to more than 12 years in prison after unlawfully receiving Medicaid beneficiaries' information and filing false claims with the Texas Medicaid program, according to the U.S. Attorney in southern Texas. A judge also ordered the former owner to pay more than $1.4 million back to Texas Medicaid.
  • A co-owner and manager of a McAllen, Texas, DME company were convicted in December of submitting fraudulent claims for power wheelchairs, according to the U.S. Attorney in southern Texas. They "falsified and forged" physician medical orders and reports and other documentation and told Medicaid that the patients received power wheelchairs when patients actually received less expensive scooters.
  • An Illinois man pleaded guilty in November to health care fraud and money laundering charges after he instructed DME company employees to obtain beneficiary information and "order as many products as possible" whether or not they were medically necessary, according to the U.S. Attorney in Rhode Island. He faces up to 33 years in prison and a fine of $760,000 and must forfeit about $2 million he received by defrauding Medicare.

3 RACs Post Issues

Along with the DME issue, Connolly posted an outpatient hospital issue. Region A RAC DCS Healthcare Services and Region D RAC HealthDataInsights also posted issues recently.

Durable medical equipment

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Incorrect payments for maintenance and servicing of capped rental DME

12/23/11

RAC Region C

Payment for maintenance and servicing of capped rental DME equipment is included in the rental payments and should not be reimbursed separately.

CGS Administrators' DMEPOS fee schedule categories website; OIG report OEI-07-08-00550; CMS Pub. 100-04, chapter 20

 

Outpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Incorrect modifiers billed with bilateral indicator 2

12/23/11

RAC Region C

Certain modifiers cannot be billed with bilateral surgery indicator 2 because the relative value units (RVUs) are already based on the procedure being performed as a bilateral procedure.

Cahaba's "How to Bill for Services with Bilateral Indicators" website; Palmetto's "Jurisdiction 1 Part B - CPT Modifier 50" website


Inpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 471, cervical spinal fusion with MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 131, cranial/facial procedures with CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 824, lymphoma-nonacute leukemia with other O.R. procedure with CC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 829, myeloproliferative disorders or poorly differentiated neoplasms with other O.R. procedure with CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 745, D&C, conization, laparoscopy and tubal interruption without CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 628, other endocrine, nutritional and metabolic O.R. procedures with MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 625, thyroid, parathyroid and thyroglossal procedures with MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 687, kidney and urinary tract neoplasms with CC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 744, D&C, conization, laparoscopy and tubal interruption with CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 735, pelvic evisceration, radical hysterectomy and radical vulvectomy without CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 659, kidney and ureter procedures and non-neoplasm with MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 949, aftercare with CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 615, adrenal and pituitary procedures without CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 946, rehabilitation without CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 915, allergic reactions with MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 034, carotid artery stent procedures with MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 755, malignancy, female reproductive system with CC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 334, rectal resection without CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 760, menstrual and other female reproductive system disorders with CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 881, depressive neuroses

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 593, skin ulcers with CC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 130, major head and neck procedures without CC/MCC

12/28/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 469, major joint replacement or re-attachment of lower extremity with MCC

12/28/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 808, major hematologic-immunologic diagnosis except sickle cell crisis and coagulation with MCC

12/28/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 904, skin grafts for injuries with CC/MCC

12/28/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

MS-DRG validation for MS-DRG 016 and 017, autologous bone marrow transplant (medical necessity excluded)

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

MS-DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches the attending physician description and the information contained in the beneficiary's medical record.

ICD-9-CM Official Guidelines for Coding and Reporting; ICD-9-CM Addendums and Coding Clinics; OIG report OAI-12-88-01010; CMS Pub. 100-08, chapter 6

MS-DRG validation for MS-DRG 570, 571 and 572, skin debridement (medical necessity excluded)

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

MS-DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches the attending physician description and the information contained in the beneficiary's medical record.

ICD-9-CM Official Guidelines for Coding and Reporting; ICD-9-CM Addendums and Coding Clinics; OIG report OAI-12-88-01010; CMS Pub. 100-08, chapter 6

Medical necessity review for MS-DRG 941, O.R. procedure with diagnoses of other contact with health services without CC/MCC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 029, spinal procedures with CC or spinal neurostimulatore

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 220, cardiac valve and other major cardiothoracic procedures without cardiac catheterization with CC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 326, stomach, esophageal and duodenal procedures with MCC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 496, local excision and removal internal fixation devices except hip and femur with CC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 746, vagina, cervix and vulva procedures with CC/MCC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 963, other multiple significant trauma with MCC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 535, fractures of hip and pelvis with MCC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 501, soft tissue procedures with CC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 835, acute leukemia without major O.R. procedure with CC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 342, appendectomy without complicated principal diagnosis with CC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 482, hip and femur procedures except major joint without CC/MCC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 596, major skin disorders without MCC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 285, acute myocardial infarction, expired without CC/MCC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 508, major shoulder or elbow procedures without CC/MCC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 166, other respiratory system O.R. procedures with MCC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 951, other factors influencing health status

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 957, other O.R. procedures for multiple significant trauma with MCC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 132, cranial/facial procedures without CC/MCC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 405, pancreas, liver and shunt procedures with MCC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 443, disorders of liver except malignancy, cirrhosis, alcoholic hepatitis without CC/MCC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 511, shoulder, elbow or forearm procedure, except major joint procedure with CC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 644, endocrine disorders with CC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 217, cardiac valve and other major cardiothoracic procedures with cardiac catheterization with CC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 896, alcohol/drug abuse or dependence without rehabilitation therapy with MCC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 645 endocrine disorder without CC/MCC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 840, lymphoma and nonacute leukemia with MCC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 084, traumatic stupor and coma, coma greater than one hour without CC/MCC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 987, nonextensive O.R. procedure unrelated to principal diagnosis with MCC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 975, HIV with major related condition with CC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 655, major bladder procedures without CC/MCC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 935, nonextensive burns

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 740, uterine, adnexa procedures for non-ovarian adnexal malignancy with CC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 940, O.R. procedure with diagnoses of other contact with health services with CC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Acute inpatient hospitalization - amputation for musculoskeletal system and connective tissue disorders with CC (DRG 475)

12/15/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute inpatient hospitalization - upper limb and toe amputation for circulatory system disorders with CC (DRG 256)

12/15/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - craniotomy with major device implant/acute complex CNS PDX without MCC (DRG 024)

12/15/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - revision of hip or knee replacement without CC/MCC (DRG 468)

12/15/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - amputation for circulatory system disorders except upper limb and toe with CC (DRG 240)

12/15/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute inpatient hospitalization - back and neck procedures except spinal fusion with CC/MCC or disc device/neurostim (DRG 490)

12/15/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - craniotomy with major device implant/acute complex CNS PDX with MCC or chemo implant (DRG 023)

12/15/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - cholesystectomy except by laparoscope without common duct exploration without CC/MCC (DRG 416)

12/15/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - major head and neck procedures without CC/MCC (DRG 130)

12/15/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute inpatient hospitalization - peripheral/cranial nerve and other nervous system procedures without CC/MCC (DRG 042)

12/15/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - cranial/facial procedures without CC/MCC (DRG 132)

12/15/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - cranial/facial procedures with CC/MCC (DRG 131)

12/15/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - craniotomy and endovascular intracranial procedures without CC/MCC

12/15/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute inpatient hospitalization - craniotomy and endovascular intracranial procedures with MCC (DRG 025)

12/15/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - peripheral/cranial nerve and other nervous system procedures with CC or peripheral neurostimulation (DRG 041)

12/15/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - carotid artery stent procedure with MCC (DRG 034)

12/15/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

 

About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

To comment on this article please go to editor@racmonitor.com

Karen Long

This email address is being protected from spambots. You need JavaScript enabled to view it.