Maryland hospitals that had received ADRs with APR-DRGs will receive updated letters with the MS-DRGs, the RAC said. DSC Healthcare said it had sent ADRs only for medical necessity review of APR 203 (chest pain) and APR-DRGs associated with MS-DRG 313 (chest pain).
The issues are below.
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 313 – chest pain (all severity and risk of mortality levels) | 7/27/11 | 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. | Section 1886(d) of Social Security Act; CMS Pub 100-08, 100-02, 100-04; Highmark LCD L27548; Maryland Health Services Cost Review Commission; Pepper Report; OIG Reports A-01-10-01000, A-03-00-00007, OAI-05-88-00730 |
Medical necessity review for MS-DRG 312 – syncope (all severity and risk of mortality levels) | 7/27/11 | 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. | Section 1886(d) of Social Security Act; CMS Pub 100-08, 100-02, 100-04; Highmark LCD L27548; Maryland Health Services Cost Review Commission; Pepper Report; OIG Reports A-01-10-01000, A-03-00-00007, OAI-05-88-00730 |
Medical necessity review for MS-DRG 069 transient ischemia (all severity and risk of mortality levels) | 7/27/11 | 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. | Section 1886(d) of Social Security Act; CMS Pub 100-08, 100-02, 100-04; Highmark LCD L27548; admission of less than 24 hours policy; Pepper Report; OIG Reports A-01-10-01000, A-03-00-00007, OAI-05-88-00730 |
Medical necessity review for MS-DRG 190, 191, 192 – chronic obstructive pulmonary disease (all severity and risk mortality levels) | 7/27/11 | 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. | Section 1886(d) of Social Security Act; CMS Pub 100-08, 100-02, 100-04; Highmark LCD L27548; admission of less than 24 hours policy; Pepper Report; OIG Reports A-01-10-01000, A-03-00-00007, OAI-05-88-00730 |