| Issue Name: |
MS-DRG Validation for Severe Sepsis (At this time, medical necessity is excluded from review.)
|
| Issue Number: |
A000382010 |
| Issue Description: |
DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRGs 177, 189, 193, 291, 438, 441, 444, 592, 602, 682, 689, 691, and 693, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
|
| Type of Review: |
DRG Validation |
| State(s) Affected: |
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Inpatient Hospitals |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
ICD-9-Cm Coding Manual (for dates of service on claim), ICD-9-CM Official Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding Clinic, PIM Chapter 6.5.3 A-C DRG Validation Review, UHDDS Reporting of Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 127) Pages 31038-31040. The Medicare Recovery Audit Contractor (RAC) Demonstration Table P3 and Table P4, Page 57. OIG Report OEI-03-98-00370, March 1999.
|
| Issue Name: |
MS-DRG Validation for Cardiac Valve Procedures (At this time, medical necessity is excluded from review.)
|
| Issue Number: |
A000562010 |
| Issue Description: |
DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRGs 216, 217, 218, 219, 220, and 221, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
|
| Type of Review: |
DRG Validation |
| State(s) Affected: |
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Inpatient Hospitals |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Official Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040
|
| Issue Name: |
MS-DRG Validation for Coronary Bypass (At this time, medical necessity is excluded from review.)
|
| Issue Number: |
A000582010 |
| Issue Description: |
DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRGs 234 and 236, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
|
| Type of Review: |
DRG Validation |
| State(s) Affected: |
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Inpatient Hospitals |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
ICD-9-CM Coding Manual (for dates of service on claim). ICD-9-CM Official Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding Clinics. PIM 6.5.3 A-C DRG Validation Review, Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040
|
| Issue Name: |
MS-DRG Validation for Lysis of Adhesions (At this time, medical necessity is excluded from review.)
|
| Issue Number: |
A000612010 |
| Issue Description: |
DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRGs 335, 336, 337, 350, 351, 352, 353, 354, and 355, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
|
| Type of Review: |
DRG Validation |
| State(s) Affected: |
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Inpatient Hospitals |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
ICD-9-CM Coding Manual (for dates of service on claim). ICD-9-CM Official Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding Clinics. PIM 6.5.3 A-C DRG Validation Review, Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040
|
| Issue Name: |
MS-DRG Validation for Excisional Debridement (At this time, medical necessity is excluded from review.)
|
| Issue Number: |
A000452009 |
| Issue Description: |
DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRGs 463, 464, 465, 573, 574, 575, 901, 902, and 903, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
|
| Type of Review: |
DRG Validation |
| State(s) Affected: |
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Inpatient Hospitals |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Official Guidelines for Coding and Reporting, ICD-9-CM addendums and Coding Clinics, PIM 6.5.3 A-C DRG Validation Review, UHDDS Reporting of Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040). The Medicare Recovery Audit Contractor (RAC) Demonstration Table G1, Page 44, Table HI, Page 45 and Appendix P1 Page 56.
|
| Issue Name: |
Technical Component of Radiology |
| Issue Number: |
A000232009 |
| Issue Description: |
A potential vulnerability may exist when the technical component (TC) of radiology services are furnished to patients in a Prospective Payment System (PPS) hospital setting and are billed separately to Part B. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B in this manner.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Physician (Carrier) / Outpatient Hospital |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
IOM 100-04, Chapter 13, Section 20.2.1,OIG Report A-01-04-00528
|
| Issue Name: |
Global vs. TC/PC Split Reimbursements |
| Issue Number: |
A000212009 |
| Issue Description: |
A potential vulnerability may exist when providers are reimbursed for global procedures and then receive additional reimbursement for technical (modifier TC) and/or professional (modifier 26) components for the same service. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B in this manner.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Physician (Carrier) / Outpatient Hospital |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
IOM 100-04, Chapter 1, section 120, IOM 100-04, Chapter 12, section 20.2,IOM 100-04, Chapter 13, Section 20.1-20.2.3,IOM 100-04, Chapter 16, pages 80.2.1
|
| Issue Name: |
IV Hydration |
| Issue Number: |
A000182009 |
| Issue Description: |
A potential vulnerability may exist if certain IV Hydration Codes are billed for more than one unit per date of service. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B in this manner.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Physician (Carrier) / Outpatient Hospital |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
IOM 100-04, Chapter 12, pages 31-32, IOM 100-20, Transmittal 419, page 7.
|
| Issue Name: |
Bronchoscopy Services |
| Issue Number: |
A000172009 |
| Issue Description: |
A potential vulnerability may exist if certain bronchoscopy services are billed for more than one unit per date of service. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B in this manner.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Physician (Carrier) / Outpatient Hospital |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
Federal Register, Volume 67, No. 251, page 8
|
| Issue Name: |
Blood Transfusions |
| Issue Number: |
A000162009 |
| Issue Description: |
A potential vulnerability may exist if certain blood transfusion codes are billed for more than one unit per date of service. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B in this manner.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Physician (Carrier) / Outpatient Hospital |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
IOM 100-04, Chapter 4, Section 231.8
|
| Issue Name: |
Untimed Codes |
| Issue Number: |
A000152009 |
| Issue Description: |
A potential vulnerability may exist if certain untimed codes are billed for more than one unit. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B in this manner.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Physician (Carrier) / Outpatient Hospital |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
IOM 100-04, Chapter 5, Section 20.2, IOM 100-04, Transmittal 1019, dated 8.3.06, pages 7-11.
|
| Issue Name: |
Neulasta |
| Issue Number: |
A000142009 |
| Issue Description: |
A potential vulnerability may exist if the code J2505 is billed with more than 1 unit per patient per date of service. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B inside of this time frame.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Physician (Carrier) / Outpatient Hospital |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
IOM 100-04, Transmittal 949 (dated May 12, 2006), HCPCS Level II 2007, 2008, 2009
|
| Issue Name: |
Once In A Lifetime |
| Issue Number: |
A000132009 |
| Issue Description: |
Certain codes may only be billed once in a lifetime. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B inside of this time frame.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Physician (Carrier) / Outpatient Hospital |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
IOM 100-08, Chapter 3 Section 3.6.
|
| Issue Name: |
Newborn/Pediatric Codes |
| Issue Number: |
A000122009 |
| Issue Description: |
Providers should not bill new Newborn/Pediatric Codes for patients which exceed the age limit defined by the CPT Code. Therefore, an issue may exist when Newborn/Pediatric Codes and are reimbursed under Medicare Part B outside of the age limit.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Physician (Carrier) / Outpatient Hospital |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
American Medical Association (AMA), Current Procedural Terminology 2007, 2008, 2009
|
| Issue Name: |
New Patient Visits |
| Issue Number: |
A000072009 |
| Issue Description: |
Providers should not bill new patient Evaluation and Management services on the same beneficiary within a 3 year period of time. Therefore, an issue may exist when multiple new patient E&M services and are reimbursed under Medicare Part B inside of this time frame.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Physician (Carrier) / Outpatient Hospital |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
IOM 100-04 Chapter 12, Section 30.6.7
|
| Issue Name: |
Duplicate Claims - Part B |
| Issue Number: |
A000462009 |
| Issue Description: |
Providers should not bill duplicate claims. Therefore, an issue may exist when duplicate services are billed and reimbursed under Medicare Part B.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Physician (Carrier) / Outpatient Hospital |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
IOM 100-04 Chapter 1, Section 120
|
| Issue Name: |
Global Billing of Radiology or Diagnostic Tests in the Facility Setting |
| Issue Number: |
A000092009 |
| Issue Description: |
Providers should not bill diagnostic tests and radiology services globally in the facility setting. Therefore, an issue may exist when these services are billed globally and reimbursed under Medicare Part B.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Physician (Carrier) / Outpatient Hospital |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
IOM 100-04 Chapter 13, Section 20.2.1, IOM 100-04 Chapter 23
|
| Issue Name: |
Global Surgery - Pre and Post-Operative Visits |
| Issue Number: |
A000032009 |
| Issue Description: |
E&M services are not allowed to be billed prior to a major surgical service without the proper modifiers. Therefore, an issue may exist when these services are billed and reimbursed under Medicare Part B without these modifiers.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Physician (Carrier) / Outpatient Hospital |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
IOM 100-04 Chapter 12, Section 40.1, 40.3
|
| Issue Name: |
National Correct Coding Initiative - Part B |
| Issue Number: |
A000022009 |
| Issue Description: |
A provider may not bill a Column II code when billed by the same provider and same date of service as a Column I code. Therefore, an issue may exist when Column II codes are billed and reimbursed under Medicare Part B in this manner.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Physician (Carrier) / Outpatient Hospital |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
IOM 100-04 Chapter 12, Section 30, IOM 100-04 Chapter 23, Section 20.9
|
| Issue Name: |
Add On Codes |
| Issue Number: |
A000122009 |
| Issue Description: |
Claims overpaid for add-on codes when the required primary procedure either was not billed or was not paid for other reasons. Therefore, an issue may exist when these codes are billed and reimbursed under Medicare Part B in this manner.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Physician (Carrier) / Outpatient Hospital |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
IOM 100-04 Chapter 12, Section 30
|
| Issue Name: |
Parenteral Nutrition Additives with Premix Solutions |
| Issue Number: |
A000522010 |
| Issue Description: |
When premix parenteral nutrition solutions are used there may not be separate billing for the carbohydrates, amino acids or additives. Therefore, an issue may exist when carbohydrates, amino acids, or additives are billed and reimbursed under Medicare Part B in this manner.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
DME Suppliers |
| Date Posted: |
June 17, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
LCD L5063, Article A37215
|
| Issue Name: |
Manual Wheelchair Accessories Billed With Power Wheelchair Bases |
| Issue Number: |
A000702010 |
| Issue Description: |
A supplier can only supply those manual wheelchair options or accessories that are defined with the code to be used with a manual wheelchair. When supplying a power wheelchair, a provider may only supply those options or accessories that are defined with the code to be used with a power wheelchair. Therefore, an issue may exist when wheelchair options and accessories are not billed and reimbursed under Medicare Part B in this manner.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
DME Suppliers |
| Date Posted: |
June 10, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
LCD L11473
|
| Issue Name: |
Initial/Preparatory Knee Disarticulation Prosthesis |
| Issue Number: |
A000692010 |
| Issue Description: |
A potential issue may exist when an above knee initial prosthesis or an above knee preparatory prosthesis is provided and certain prosthetic substitutions and/or additions are billed at the same time. Therefore, an issue may exist when these substitutions and/or additions are billed and reimbursed under Medicare Part B in this manner.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
DME Suppliers |
| Date Posted: |
June 10, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
LCD L11464
|
| Issue Name: |
MS-DRG Validation for Liver Transplant (At this time, medical necessity is excluded from review.)
|
| Issue Number: |
A000502010 |
| Issue Description: |
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 both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 006; principal diagnosis, secondary diagnoses, and procedures affecting or potentially affecting the MS-DRG.
|
| Type of Review: |
DRG Validation |
| State(s) Affected: |
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Inpatient Hospitals |
| Date Posted: |
May 11, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
ICD-9-CM Coding Manual ( for dates of service on claim), ICD-9-CM Addendums and Coding Clinics, PIM
Chapter 6.5.3 Section A - C DRG Validation Review, Uniform Hospital Discharge Data Set (UHDDS) -
Reporting of inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 31038-
31040.
|
| Issue Name: |
MS-DRG Validation for Heart Transplant (At this time, medical necessity is excluded from review.)
|
| Issue Number: |
A000512010 |
| Issue Description: |
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 both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 002; principal diagnosis, secondary diagnoses, and procedures affecting or potentially affecting the MS-DRG.
|
| Type of Review: |
DRG Validation |
| State(s) Affected: |
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Inpatient Hospitals |
| Date Posted: |
May 11, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
ICD-9-CM Coding Manual ( for dates of service on claim), ICD-9-CM Addendums and Coding Clinics, PIM
Chapter 6.5.3 Section A - C DRG Validation Review, Uniform Hospital Discharge Data Set (UHDDS) -
Reporting of inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 31038-
31040.
|
| Issue Name: |
MS-DRG Validation for HIV (At this time, medical necessity is excluded from review.)
|
| Issue Number: |
A000422009 |
| Issue Description: |
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 both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate claims where diagnosis code 042 Human Immunodeficiency Virus (HIV) Disease was billed as secondary. Principal diagnosis, secondary diagnoses, and procedures affecting or potentially affecting the claim will be reviewed for accuracy.
|
| Type of Review: |
DRG Validation |
| State(s) Affected: |
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Inpatient Hospitals |
| Date Posted: |
May 11, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9 CM Official Guidelines for Coding and
Reporting, ICD-9-CM Addendums and Coding Clinics, PIM Ch 6.5.3 A-C DRG Validation Review; UHDDS -
Reporting of Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 127), Pages 31038-
31040.
|
| Issue Name: |
IPPS Hospital to Hospital Transfers |
| Issue Number: |
A000082009 |
| Issue Description:
|
Medicare pays full MS-DRG payments to the final discharging hospital, while payment to the transferring hospital is often based upon a per diem rate (depending on the length of stay). Therefore, an improperly reported transfer may result in an overpayment when both hospitals receive full MS-DRG payments.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Inpatient Hospitals |
| Date Posted: |
March 31, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
Section 1886(d) of the Social Security Act, Internet-Only Manual (IOM), Publication 100-04, Chapter 3, Sections 20.1.2.4 and 40.2.4, Code of Federal Regulations 42 CFR 412.4
|
| Issue Name: |
MS-DRG Validation for Cardiac Procedures (At this time, medical necessity is excluded from review.)
|
| Issue Number: |
A000412009 |
| Issue Description: |
DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRGs 228, 231, 233, 235, 237, 248, and 250, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
|
| Type of Review: |
DRG Validation |
| State(s) Affected: |
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Inpatient Hospitals |
| Date Posted: |
March 23, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Addendums and Coding Clinics, PIM Ch 6.5.3, Section A-C, DRG Validation Review, DRG Desk Reference Ingenix 2009. CodeWrite, April 2007; AHIMA
|
| Issue Name: |
MS-DRG Validation for Major Large and Small Bowel Procedures (At this time, medical necessity is excluded from review.)
|
| Issue Number: |
A000402009
|
| Issue Description: |
DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRGs 329, 330, and 331, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
|
| Type of Review: |
DRG Validation |
| State(s) Affected: |
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Inpatient Hospitals |
| Date Posted: |
March 23, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Addendums and Coding Clinics, PIM Ch 6.5.3, Section A-C, DRG Validation Review, DRG Desk Reference Ingenix 2009. CodeWrite, April 2007; AHIMA.
|
| Issue Name: |
MS-DRG Validation for Intracranial Hemorrhage or Cerebral Infarction (At this time, medical necessity is excluded from review.)
|
| Issue Number: |
A000432009
|
| Issue Description: |
DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRGs 061, 062, 063, 064, 065, 066, 067, 068, 069, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
|
| Type of Review: |
DRG Validation |
| State(s) Affected: |
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Inpatient Hospitals |
| Date Posted: |
March 23, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Addendums and Coding Clinics, PIM Ch 6.5.3, Section A-C, DRG Validation Review, DRG Desk Reference Ingenix 2009. CodeWrite, April 2007; AHIMA.
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| Issue Name: |
Oxygen Accessories |
| Issue Number: |
A000332009 |
| Issue Description: |
A potential issue may exist if certain oxygen accessories are billed when an oxygen system rental has been billed in the month prior to the date of service or in the subsequent month. Therefore, an issue may exist when these accessories are billed and reimbursed under Medicare Part B in this manner.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
DME Suppliers |
| Date Posted: |
February 10, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References |
LCD L11468; LCD Policy Article A33768
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| Issue Name: |
MS-DRG Validation for MS-DRGs with Ventilator Support of 96+ Hours (At this time, Medical Necessity is excluded from review.) |
| Issue Number: |
A000302009 |
| Issue Description: |
DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS DRGs 003, 004, 207, 870, 927 and 933; principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
|
| Type of Review: |
DRG Validation |
| State(s) Affected: |
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Inpatient Hospitals |
| Date Posted: |
January 19, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Addendums and Coding Clinics, PIM Ch 6.5.3, Section A - C - DRG Validation Review, DRG Desk Reference Ingenix 2009. CodeWrite, April 2007; AHIMA
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| Issue Name: |
MS-DRG Validation for MS-DRG 189 Pulmonary Edema & Respiratory Failure (At this time, Medical Necessity is excluded from review.) |
| Issue Number: |
A000352009 |
| Issue Description: |
DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 189, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
|
| Type of Review: |
DRG Validation |
| State(s) Affected: |
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Inpatient Hospitals |
| Date Posted: |
January 19, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Addendums and Coding Clinics, PIM Ch 6.5.3, Section A - C - DRG Validation Review, OIG Report DRG 87: Pulmonary Edema and Respiratory Failure, August 1989
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| Issue Name: |
MS-DRG Validation for MS-DRGs for Tracheostomy (At this time, Medical Necessity is excluded from review.) |
| Issue Number: |
A000362009 |
| Issue Description: |
DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS DRGs 003, 004, 011, 012, 013; principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
|
| Type of Review: |
DRG Validation |
| State(s) Affected: |
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Inpatient Hospitals |
| Date Posted: |
January 19, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Addendums and Coding Clinics, PIM Ch 6.5.3 A-C DRG Validation Review; UHDDS - Reporting of Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 31038-31040
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| Issue Name: |
Ambulance Unbundled Services During an Inpatient Hospital Stay |
| Issue Number: |
A00062009 |
| Issue Description: |
Ambulance services should be billed to the inpatient provider for services for inpatients. Therefore, an issue may exist when a beneficiary received ambulance services during an inpatient stay, which have been billed and reimbursed under Medicare Part B.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
Ambulance Providers |
| Date Posted: |
January 07, 2010 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
Internet Only Manual, Medicare Benefit Policy Manual Publication 100-02 Chapter 10, Section 10 and 10.3.3.
Internet Only Manual, Medicare Processing Manual, Publication 100-04, Chapter 3, Sections 10.4 and 10.5.
Internet Only Manual, Medicare Claims Processing Manual, Publication 100-04, Chapter 15, Section 10.2, Summary of Benefit and 30.A, Modifier specific to Ambulance Services.
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| Issue Name: |
Solid Insert with Seat or Back Wheelchair Cushions |
| Issue Number: |
A000262009 |
| Issue Description: |
Code E0992 (solid seat insert) is not separately payable when provided with a seat or a seat back wheelchair cushion. Therefore an issue may exist when E0992 is billed and reimbursed under Medicare Part B with a seat or seat back wheelchair cushion.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
DME Suppliers |
| Date Posted: |
December 22, 2009 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
LCD Policy Article A17918
|
| Issue Name: |
Lower Limb Suction Valve Prosthesis |
| Issue Number: |
A000252009 |
| Issue Description: |
Codes L5647 and L5652 describe a modification to a prosthetic socket that incorporates a suction valve in the design. The items described by these codes are not components of a suspension locking mechanism (L5671). Therefore, an issue may exist when such a locking mechanism is billed and reimbursed under Medicare Part B along with a suction valve suspension.
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| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
DME Suppliers |
| Date Posted: |
December 22, 2009 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
LCD Policy Article A25310, Region A DMERC PSC Bulletin
|
| Issue Name: |
Prosthetic Additions with Initial or Preparatory Knee Prosthesis |
| Issue Number: |
A000282009 |
| Issue Description: |
When an initial below knee prosthesis (L5500) or a preparatory below knee prosthesis (L5510-L5530, L5540) is provided, prosthetic substitutions and/or additions of procedures and components are covered in accordance with the functional level assessment, except for certain codes. Therefore, an issue may exist when these codes are billed and reimbursed under Medicare Part B with such a prosthesis.
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| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
DME Suppliers |
| Date Posted: |
December 22, 2009 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
LCD Policy L11464
|
| Issue Name: |
Multiple DME Rentals within a Month |
| Issue Number: |
A000042009 |
| Issue Description: |
Certain procedure codes may not be billed in conjunction with other procedure codes for the same date of service and for the same beneficiary. Therefore an issue may exist when these codes are billed and reimbursed under Medicare Part B on the same date of service and for the same beneficiary.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
DME Suppliers |
| Date Posted: |
December 22, 2009 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
CMS Pub 100-04, Ch 20, § 30.1, 30.2, 30.5, 30.7, 130.8, Social Security Act, Volume I, Title XVIII, Section 1834
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| Issue Name: |
Headrest with a Power Operated Vehicle or a Power Wheelchair with a Captain's Chair Seat |
| Issue Number: |
A000272009 |
| Issue Description: |
Headrests (E0955) may not be billed on the same date of service as a Power Operated Vehicle (POV) or Power Wheelchair (PWC) with a captain's chair seat. Therefore, an issue may exist when a beneficiary receives a Power Operated Vehicle (POV) or Power Wheelchair (PWC) with a captain's chair seat and a headrest, which has been billed and reimbursed under Medicare Part B, on the same date of service.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
DME Suppliers |
| Date Posted: |
December 22, 2009 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
LCD Policy L15845
|
| Issue Name: |
Wheel Attachment with New Non-Wheeled Walker |
| Issue Number: |
A000292009 |
| Issue Description: |
Wheel attachment (E0155) cannot be paid on the same day or within one month of the initial issue of a nonwheeled walker. Therefore, an issue may exist when a beneficiary receives this wheel attachment, which has been billed and reimbursed under Medicare Part B, within a month of an initial issue of a nonwheeled walker.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
DME Suppliers |
| Date Posted: |
December 22, 2009 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
LCD Policy L11472
|
| Issue Name: |
Pharmacy Supply and Dispensing Fees |
| Issue Number: |
A000052009 |
| Issue Description: |
Pharmacy supply and dispensing fees when billed by a DME supplier are required to be accompanied with an oral anti-cancer, oral anti-emetic, immunosuppressive drug or inhalation drug. The absence of one of the aforementioned drugs billed on the same date of service or a denial of one of the aforementioned drugs represents a potential issue.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
DME Suppliers |
| Date Posted: |
September 18, 2009 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
Internet Only Manual 100-04 (Medicare Claims Processing Manual), Chapter 17 (Drugs and Biologicals), Section 80.7. Transmittal 754, Change Request 3990, Requirement 3990.15. DME MAC Jurisdiction A Article for Nebulizers A24944 (LCD L11499). DME MAC Jurisdiction A Article for Oral Anticancer Drugs A25227 (LCD L5057). DME MAC Jurisdiction A Article for Oral Antiemetic Drugs A25228 (LCD L5058). DME MAC Jurisdiction A Article for Immunosuppressive Drugs A23662 (LCD L11531).
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| Issue Name: |
Wheelchair Bundling |
| Issue Number: |
A000202009 |
| Issue Description: |
A potential issue may exist if certain procedure codes are billed in conjunction with other procedure codes for the same date of service and the same beneficiary.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
DME Suppliers |
| Date Posted: |
September 18, 2009 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
LCD L11473, CMS Pub 100-03, Ch 1, § 280.1 & 280.3
|
| Issue Name: |
Urological Bundling |
| Issue Number: |
A000192009 |
| Issue Description: |
A potential issue may exist if certain urological procedure codes are billed in conjunction with other urological procedure codes for the same date of service and same beneficiary.
|
| Type of Review: |
Automated Review for Overpayments |
| State(s) Affected: |
DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: |
DME Suppliers |
| Date Posted: |
September 18, 2009 |
| Dates of Service: |
October 1, 2007 - Present |
| Issue References: |
CMS Pub.100-3, Ch1, § 230.17; LCD L5080 LCD Policy Article 25230
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