November 6, 2011

RAC Issue Follows OIG Report, Targets Power Wheelchairs

By Karen Long

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CGI Federal, the recovery auditor for RAC Region B, will review documentation for medical necessity and coding requirements for claims with new power wheelchairs, according to an issue approved Oct. 26.

Payments for power wheelchairs have been a target of the Office of Inspector General (OIG). A July 2011 OIG report noted that 61 percent of power wheelchairs provided to beneficiaries in the first half of 2007 “where medically unnecessary or had claims that lacked sufficient documentation to determine medical necessity,” the OIG states. Those claims accounted for $95 million of the $189 million paid for power wheelchairs during that time.

DCS Healthcare, the RAC for Region A, posted a power-wheelchair issue in February and has other wheelchair-related issues on its list. HealthDataInsights, the Region D RAC, posted a power wheelchair issue in April.

Connolly, the Region C RAC, has a wheelchair bundling issues posted.

DCS Healthcare also posted 31 inpatient issues – three for Maryland and 28 for the other states in the region.

For more on the recently posted issues, see below.

Durable medical equipment by supplier

Name of issue	Date posted or approved	Regions/states where it is active	Description of issue	Document sources
New purchased power wheelchairs – groups 1, 2, 3	10/26/11	RAC Region B	Power wheelchairs – groups 1, 2, 3 are covered if the equipment is properly coded and meets coverage criteria/ documentation requirements specified in the National Government Services (NGS) LCD L27239, effective Oct. 1, 2006. Medical records will be reviewed for new, purchased PWC–Group 1,2,3 (HCPCS K0813-K0864 with modifiers NU-new equipment and BP-beneficiary elected to purchase item) for appropriate coding, documentation requirements and medical necessity criteria.	CMS Pub. 100-02, chapter 15; CMS Pub. 100-03, chapter 1; CMS Pub. 100-04, chapter 20; CMS Pub. 100-08, chapter 5; NGS LCD L27239; NGS article A47122; NGS Jurisdiction B Supplier Manual chapters 8, 9, 15, 17; MLN Matters SE1112; MLN Fact Sheet – Power Mobility Devices; NGS toosl and resources, Dear Physician letters

Inpatient hospital

Name of issue	Date posted or approved	Regions/states where it is active	Description of issue	Document sources
Medical necessity review – MS-DRG 238, major cardiovascular procedures without MCC	11/2/11	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 237, major cardiovascular procedures with MCC	11/2/11	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 460, spinal fusion except cervical without MCC	11/2/11	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 207, respiratory system diagnosis with ventilator support 96+ hours	11/2/11	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 708, major male pelvic procedures without CC-MCC	11/2/11	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 627, thyroid, parathyroid and thyroglossal procedure without CC-MCC	11/2/11	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 419, laparoscopic cholecystectomy without C.D.E. without CC-MCC	11/2/11	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 743, uterine and adnexa procedure for nonmalignancy without CC-MCC	11/2/11	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 621, O.R. procedures for obesity without CC-MCC	11/2/11	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 714, transurethral prostatectomy without CC-MCC	11/2/11	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 490, back and neck procedures except spinal fusion with CC-MCC or disc device/ neurostimulator	11/2/11	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 748, female reproductive system reconstructive procedures	11/2/11	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 038, extracranial procedures with CC	11/2/11	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 484, major joint-limb reattachment procedures of upper extremity without CC-MCC	11/2/11	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 036, carotid artery stent procedure without CC-MCC	11/2/11	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 917, poisoning and toxic effects of drugs with MCC	10/28/11	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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 516, other musculoskeletal system and connective tissue O.R. procedure with CC	10/28/11	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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730
Medical necessity review – MS-DRG 897 alcohol/drug abuse or dependence without rehabilitation therapy without MCC	10/28/11	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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730
Medical necessity review – MS-DRG 813, coagulation disorders	10/28/11	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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730
Medical necessity review – MS-DRG 894, alcohol/drug abuse or dependence, left against medical advice	10/28/11	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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730
Medical necessity review – MS-DRG 082, traumatic stupor and coma, coma greater than one hour with MCC	10/28/11	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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 054, nervous system neoplasms with MCC	10/28/11	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-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730
Medical necessity review – MS-DRG 291, heart failure and shock with MCC; MS-DRG 292, heart failure and shock with CC; MS-DRG 293, heart failure and shock without CC/MCC	10/27/11	Md.	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.	Sects. 1886(d) and 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; CMS Change Request 3200; Highmark LCD L27548; Admission of less than 24 hours policy; Pepper report; OIG reports A-01-10-0100, A-03-00-00007, OAI-05-88-00730
Medical necessity review – MS-DRG 302, atherosclerosis with MCC, and MS-DRG 303, atherosclerosis without MCC	10/27/11	Md.	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.	Sects. 1886(d) and 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; CMS Change Request 3200; Highmark LCD L27548; Admission of less than 24 hours policy; Pepper report; OIG reports A-01-10-0100, A-03-00-00007, OAI-05-88-00730
Medical necessity review – MS-DRG 516, other musculoskeletal system and connective tissue O.R. procedure with CC	10/27/11	Md.	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.	Sects. 1886(d) and 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; CMS Change Request 3200; Highmark LCD L27548; Admission of less than 24 hours policy; Pepper report; OIG reports A-01-10-0100, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 200, pneumothorax with CC	10/27/11	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 307, cardiac congenital and valvular disorders without MCC	10/27/11	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 187, pleural effusion with CC	10/27/11	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 186, pleural effusion with MCC	10/27/11	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 184, major chest trauma with CC	10/27/11	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 081, nontraumatic stupor and coma without MCC	10/27/11	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.