Updated on: January 31, 2013

More RAC Targets Reflect OIG Focus in 2012 Work Plan

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Original story posted on: November 14, 2011

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Another issue posted by a recovery auditor closely resembles targets the Office of Inspector General will focus on in 2012.

Connolly, the Region C RAC, will review whether services provided to patients at inpatient rehabilitation facilities (IRF) are medically necessary, according to an issue approved Nov. 9.

In its 2012 Work Plan, OIG published a new issue examining whether admissions to inpatient rehabilitation facilities are appropriate. “Patients must undergo preadmission screening and evaluation to ensure that they are appropriate candidates for IRF care,” OIG states in its Work Plan.

Connolly plans to evaluate documentation in patient records to ensure patients:

  • Need “active and ongoing therapeutic intervention of multiple therapy disciplines,” one of which has to be physical therapy or occupational therapy;
  • Require intensive rehabilitation therapy;
  • At the time of admission to the IRF must reasonably be expected to “actively participate in an benefit significantly from” the intensive therapy;
  • Require supervision by rehabilitation physicians who conduct visits with patients at least three days per week during their stay in the IMF; and
  • Needs “intensive and coordinated interdisciplinary approach to providing rehabilitation.”

Also last week, several inpatient issues were posted by DCS Healthcare in RAC Region A and HealthDataInsights in RAC Region D. Connolly also posted three other issues.

Inpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity: Inpatient rehabilitation facility (IRF) patients not meeting medical necessity criteria

11/9/11

RAC Region C

To be reasonable and necessary, documentation in the patient’s record must demonstrate at the time of admission to IRF that:

·The patient requires active and ongoing therapeutic intervention of multiple therapy disciplines, one of which must be physical or occupational therapy

·The patient must generally require an intensive rehabilitation therapy program, as defined in section 110.2.2

·The patient must reasonably be expected to actively participate in and benefit significantly from the intensive rehabilitation therapy program that is defined in section 110.2.2 at the time of admission to the IRF

·The patient must require physician supervision by a rehabilitation physician defined as a licensed physician with specialized training and experience in inpatient rehabilitation. The medical supervision requirement means the rehabilitation physician must conduct face-to-face visits with the patient at least three days per week during the patient’s stay in the IRF to assess the patient medically and functionally and modify treatment as needed to maximize the patient’s capacity to benefit from rehabilitation

·The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation as defined in section 11.2.5

CMS Pub. 100-02 chapter 1; Highmark Part A Bulletins


 

Medical necessity review – MS-DRG 042 peripheral-cranial nerve and other nervous system procedures without CC-MCC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 033 ventricular shunt procedures without CC-MCC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – 710 penis procedures without CC-MCC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 494 lower extremity-humerus procedures except hip, foot, femur without CC-MCC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 472 cervical spinal fusion with CC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

 
 

 

Medical necessity review – MS-DRG 853 infectious-parasitic diseases with O.R. procedure with MCC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 512 shoulder, elbow or forearm procedure, except major joint procedure without CC-MCC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 580 other skin, subcutaneous tissue and breast procedures with CC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 517 other musculoskeletal system and connective tissue O.R. procedure without CC-MCC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 983 extensive O.R. procedure unrelated to principal diagnosis without CC-MCC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

 

 

Medical necessity review – MS-DRG 582 mastectomy for malignancy without CC-MCC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 165 major chest procedure without CC-MCC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 479 biopsies of musculoskeletal system and connective tissue without CC-MCC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 418 laparoscopic cholecystectomy without C.D.E. with CC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 328 stomach, esophageal, duodenal procedures without CC-MCC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

 
 

Medical necessity review – MS-DRG 713 transurethral prostatectomy with CC-MCC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 982 extensive O.R. procedure unrelated to principal diagnosis with CC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 041 peripheral-cranial nerve and other nervous system procedures with CC or peripheral neurostimulator

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 030 spinal procedures without CC-MCC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 164 major chest procedure with CC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

 

Medical necessity review – MS-DRG 470 major joint replacement or reattachment of lower extremity without MCC

11/8/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 155 other ear, nose, mouth, throat diagnosis with CC

11/7/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Bone marrow transplant: MS-DRG 014 and 015 (previously DRG 009); medical necessity excluded

11/7/11

RAC Region C

DRG validation requires that diagnostic and procedural information and beneficiary discharge status, as coded and reported by the hospital on its claims, matches the attending physician description and information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 014 and 015 principal diagnosis, secondary diagnosis and procedures affecting or potentially affecting the DRG.

ICD-9-CM Addendums and Coding Clinics (2007-2009); ICD-9-CM Vol. 1, 2, 3, coding manuals (2007-2009); CMS Pub. 100-08 chapter 6

Medical necessity: Disease and disorders of the ear, nose, mouth, throat

11/7/11

RAC Region C

RACs will review documentation to validate medical necessity of short stay, uncomplicated admissions. Documentation will be reviewed to determine that the services were medically necessary and billed correctly for MS-DRGs 153, 158, 159. RACs also will review documentation to validate MS-DRG 153, 158, 159 requiring 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 information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG, principal diagnosis, secondary diagnosis and procedures affecting or potentially affecting the DRG.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapters 6, 13; CMS RAC demonstration evaluation report

 
 
 
 
 
 
 

Medical necessity: postoperative or post-traumatic infections with O.R. procedures without CC/MCC; MS-DRG 858

11/4/11

RAC Region C

RACs will review documentation to validate medical necessity of short stay, uncomplicated admissions. Medical documentation will be reviewed to determine that the services were medically necessary and billed correctly for MS-DRG 858. RACs also will review documentation to validate MS-DRG 858 requiring 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 information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG, principal diagnosis, secondary diagnosis and procedures affecting or potentially affecting the DRG.

CMS Pub. 100-02 chapter 1; CMS Pub. 100-08 chapter 6; RAC demonstration evaluation report

Medical necessity review – MS-DRG 027 craniotomy and endovascular intracranial procedures without CC-MCC

11/4/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 581 other skin, subcutaneous tissue and breast procedures without CC-MCC

11/4/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

 
 

 

Medical necessity review – MS-DRG 100 seizures with MCC

11/4/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 176 pulmonary embolism without MCC

11/4/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 085 nontraumatic stupor and coma, coma less than one hour with MCC

11/4/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 432 cirrhosis and alcoholic hepatitis with MCC

11/4/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 175 pulmonary embolism with MCC

11/4/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

 
 

 

Medical necessity review – MS-DRG 306 cardiac congenital and valvular disorders with MCC

11/4/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 201 pneumothorax without CC-MCC

11/4/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 061 acute ischemic stroke with use of thrombolytic agent with MCC

11/4/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 728 inflammation of the male reproduction system without MCC

11/4/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 185 major chest trauma without CC-MCC

11/4/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

 
 
 

Medical necessity review – MS-DRG 147 ear, nose, mouth, throat malignancy with CC

11/4/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 080 nontraumatic stupor and coma with MCC

11/4/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 148 ear, nose, mouth, throat malignancy without CC-MCC

11/4/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 592 skin ulcers with MCC

11/4/11

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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

 
 

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

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Karen Long

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