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					                                 DCS approved audit issues
                                      Updated as of 04/27/2011


               Medical Necessity Review (MNR) for MS-DRG 604 Trauma to the Skin,
Issue Name:
               Subcutaneous Tissue & Breast with MCC
Issue
               A000692011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 604
               Trauma to the Skin, Subcutaneous Tissue & Breast with MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 058 Multiple Sclerosis and
Issue Name:
               Cerebellar Ataxia with MCC
Issue
               A000702011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 058
               Multiple Sclerosis and Cerebellar Ataxia with MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 059 Multiple Sclerosis and
Issue Name:
               Cerebellar Ataxia with CC
Issue
               A000712011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 059
               Multiple Sclerosis and Cerebellar Ataxia with CC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";
               Medical Necessity Review (MNR) for MS-DRG 060 Multiple Sclerosis and
Issue Name:
               Cerebellar Ataxia without CC/MCC
Issue
               A000722011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 060
               Multiple Sclerosis and Cerebellar Ataxia without CC/MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 064 Intracranial Hemorrhage
Issue Name:
               or Cerebral Infarction with MCC
Issue
               A000732011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 064
               Intracranial Hemorrhage or Cerebral Infarction with MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of       Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 065 Intracranial Hemorrhage
Issue Name:
               or Cerebral Infarction with CC
Issue
               A000742011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 065
               Intracranial Hemorrhage or Cerebral Infarction with CC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 066 Intracranial Hemorrhage
Issue Name:
               or Cerebral Infarction without CC/MCC
Issue
               A000752011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 066
               Intracranial Hemorrhage or Cerebral Infarction without CC/MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




Issue Name: Medical Necessity Review (MNR) for MS-DRG 089 Concussion with CC
Issue
               A000762011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 089
               Concussion with CC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
Issue
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
References
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




Issue Name: Medical Necessity Review (MNR) for MS-DRG 638 Diabetes with CC
Issue
               A000772011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 638
               Diabetes with CC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 639 Diabetes without
Issue Name:
               CC/MCC
Issue
               A000782011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 639
               Diabetes without CC/MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 091 Other Disorders of
Issue Name:
               Nervous System with MCC
Issue
               A000792011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 091
               Other Disorders of Nervous System with MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
Issue
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
References
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 092 Other Disorders of
Issue Name:
               Nervous System with CC
Issue
               A000802011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 092
               Other Disorders of Nervous System with CC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 093 Other Disorders of
Issue Name:
               Nervous System without CC/MCC
Issue
               A000812011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 093
               Other Disorders of Nervous System without CC/MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




Issue Name: Medical Necessity Review (MNR) for MS-DRG 149 Dysequilibrium
Issue
               A000822011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 149
               Dysequilibrium
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";
               Medical Necessity Review (MNR) for MS-DRG 157 Dental & Oral Diseases
Issue Name:
               w MCC
Issue
               A000832011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 157
               Dental & Oral Diseases w MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 158 Dental & Oral Diseases
Issue Name:
               with CC
Issue
               A000842011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 158
               Dental & Oral Diseases with CC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
Issue          Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
References     Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 159 Dental & Oral Diseases
Issue Name:
               without CC/MCC
Issue
               A000852011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 159
               Dental & Oral Diseases without CC/MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 181 Respiratory Neoplasms
Issue Name:
               with CC
Issue
               A000862011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 181
               Respiratory Neoplasms with CC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 233 Coronary Bypass w
Issue Name:
               Cardiac cath with MCC
Issue
               A000882011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 233
               Coronary Bypass w Cardiac cath with MCC
Type of
               Medical Necessity Review
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ excluding Maryland
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
Issue          Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
References     Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 113 Orbital Procedures with
Issue Name:
               CC/MCC
Issue
               A000492011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 113
               Orbital Procedures with CC/MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 26, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




Issue Name: Medical Necessity Review (MNR) for MS-DRG 088 Concussion with MCC
Issue
               A000502011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 088
               Concussion with MCC
Type of        Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 26, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 117 Intraocular Procedures
Issue Name:
               without CC/MCC
Issue
               A000512011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 117
               Intraocular Procedures without CC/MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 26, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
Issue          Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
References     Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 847 Chemotherapy without
Issue Name:
               Acute Leukemia as secondary diagnoses with CC
Issue
               A000522011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 847
               Chemotherapy without Acute Leukemia as secondary diagnoses with CC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 26, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 848 Chemotherapy w/o Acute
Issue Name:
               Leukemia as secondary diagnosis w/o CC/MCC
Issue
               A000532011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 848
               Chemotherapy w/o Acute Leukemia as secondary diagnosis w/o CC/MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers      Inpatient Hospitals
Affected:
Date Posted: April 26, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3;; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter
               1, Section 10; IOM, Publication 100-04, Medicare Claims Processing
               Manual, Chapter 3, Section 40.2.2 (K); Local Coverage Determination
Issue
               Highmark Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper
References
               Report "Top 20 DRGs for One-day Stays for Short-term Acute Care
               Hospitals"; Office of Inspector General (OIG) Report A-01-10-01000
               "Analysis of Errors IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-
               00880, "National DRG Validation Study Unnecessary Admissions to
               Hospitals"; OIG Report A-03-00-00007, "Review of the HCFA PA Regional
               Offices Effort to ID Overpayments for 1-Day In-Patient Stays"; OIG Report
               OAI-05-88-00730, "National DRG Validation Study: Short Hospitalizations";




Issue Name: Medical Necessity Review (MNR) for MS-DRG 637 Diabetes with MCC
Issue
               A000542011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 637
               Diabetes with MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 26, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); OM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";
               Medical Necessity Review (MNR) for MS-DRG 152 Otitis Media and URI with
Issue Name:
               MCC
Issue
               A000552011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 152 Otitis
               Media and URI with MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 26, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 974 HIV with Major Related
Issue Name:
               Condition with MCC
Issue
               A000562011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 974 HIV
               with Major Related Condition with MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 26, 2011
Dates of
               Rolling 36 month review look back
Service:
Issue          Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
References     Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 121 Acute Major Eye
Issue Name:
               Infections with CC/MCC
Issue
               A000572011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 121
               Acute Major Eye Infections with CC/MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 26, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 122 Acute Major Eye
Issue Name:
               Infections without CC/MCC
Issue
               A000582011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 122
               Acute Major Eye Infections without CC/MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 26, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 137 Mouth Procedures with
Issue Name:
               CC/MCC
Issue
               A000592011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 137
               Mouth Procedures with CC/MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 26, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
Issue          Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
References     Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 502 Soft Tissue Procedures
Issue Name:
               without CC/MCC
Issue
               A000602011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 502 Soft
               Tissue Procedures without CC/MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 26, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 846 Chemotherapy without
Issue Name:
               Acute Leukemia as secondary diagnoses with MCC
Issue
               A000482011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 846
               Chemotherapy without Acute Leukemia as secondary diagnoses with MCC
Type of
               Medical Necessity Review
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 25, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 575 Skin Graft &/or for Skin
Issue Name:
               Ulcer or Cellulitis without CC/MCC
Issue
               A000442011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 575 Skin
               Graft &/or for Skin Ulcer or Cellulitis without CC/MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 7, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
Issue
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
References
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 003 ECMO or Tracheostomy
Issue Name:
               with MV 96+ hrs or PDX Except Face, Mouth and Neck with Major O.R.
Issue
               A000452011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
               the setting billed. Medical documentation will be reviewed to determine that
Issue
               services were medically necessary. This review will be of MS-DRG 003
Description:
               ECMO or Tracheostomy with MV 96+ hrs or PDX Except Face, Mouth and
               Neck with Major O.R.
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 7, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; OM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 040 Peripheral/Cranial Nerve
Issue Name:
               and Other Nervous System Procedures with MCC
Issue
               A000472011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 040
               Peripheral/Cranial Nerve and Other Nervous System Procedures with MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: April 7, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); CMS Internet-
               Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
               Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
               Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
               13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
               Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
               Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
               Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
               "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
               Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
               IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
               DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
               03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
               Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
               "National DRG Validation Study: Short Hospitalizations";




               MS-DRG Validation: MDC 19-Mental Diseases And Disorders MS-DRGs:
Issue Name:    876, 880, 881, 882, 883, 884, 885, 886, and 887 (Medical Necessity
               Excluded)
Issue
               A000612011
Number
               MS-DRG validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded by the hospital on its claim,
Issue          matches both the attending physician description and the information
Description:   contained in the medical record. Reviewers will validate MS-DRGs 876, 880,
               881, 882, 883, 884, 885, 886 and 887 for principal and secondary diagnoses
               and procedures affecting or potentially affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 25, 2011
Dates of
               Rolling 36 month review look back
Service:
               Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99); PIM,
Issue          Chapter 6.5.3 DRG Validation Review; Uniform Hospital Discharge Data Set
References     (UHDDS) Reporting of Inpatient Data Elements, July 31, 1985; Federal
               Register (Vol.50, No. 147) Pages 31038-31040;




               MS-DRG Validation: MDC 20-Alcohol/Drug Use And Alcohol/Drug-Induced
Issue Name:    Organic Mental Disorders MS-DRG 894, 895, 896 and 897 (Medical
               Necessity Excluded)
Issue
               A000622011
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate MS-DRGs 894, 895, 896 and 897 for principal and secondary
               diagnoses and procedures affecting or potentially affecting the MS-DRG
               assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT. PA, DE, DC, RI, CT, NJ: excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 25, 2011
Dates of
               Rolling 36 month review look back
Service:
               Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99); PIM,
Issue          Chapter 6.5.3 DRG Validation Review; Uniform Hospital Discharge Data Set
References     (UHDDS) Reporting of Inpatient Data Elements, July 31, 1985; Federal
               Register (Vol.50, No. 147) Pages 31038-31040;




               MS-DRG Validation: Burns MS-DRGs 928, 929, 934 and 935 (Medical
Issue Name:
               Necessity Excluded)
Issue
               A000632011
Number
               MS-DRG validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded by the hospital on its claim,
Issue          matches both the attending physician description and the information
Description:   contained in the medical record. Reviewers will validate MS-DRGs 928, 929,
               934 and 935 for principal and secondary diagnoses and procedures affecting
               or potentially affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ: excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 25, 2011
Dates of
               Rolling 36 month review look back
Service:
               Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99); PIM,
Issue          Chapter 6.5.3 DRG Validation Review; Uniform Hospital Discharge Data Set
References     (UHDDS) Reporting of Inpatient Data Elements, July 31, 1985; Federal
               Register (Vol.50, No. 147) Pages 31038-31040;




               MS-DRG Validation: MDC 23-Factors Influencing Health Status & Other
Issue Name:    Contacts with Health Services MS-DRGs 939, 940, 941, 945, 946, 947, 948,
               949, 950 and 951 (Medical Necessity Excluded)
Issue          A000642011
Number
               MS-DRG validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded by the hospital on its claim,
               matches both the attending physician description and the information
Issue
               contained in the medical record. Reviewers will validate MS-DRGs 939, 940,
Description:
               941, 945, 946, 947, 948, 949, 950 and 951 for principal and secondary
               diagnoses and procedures affecting or potentially affecting the MS-DRG
               assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 25, 2011
Dates of
               Rolling 36 month review look back
Service:
               Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99); PIM,
Issue          Chapter 6.5.3 DRG Validation Review; Uniform Hospital Discharge Data Set
References     (UHDDS) Reporting of Inpatient Data Elements, July 31, 1985; Federal
               Register (Vol.50, No. 147) Pages 31038-31040;




               MS-DRG Validation: MDC-24 Multiple Significant Trauma MS-DRGs 955,
Issue Name:
               956, 957, 958, 959, 963, 964 and 965 (Medical Necessity Excluded)
Issue
               A000652011
Number
               MS-DRG validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded by the hospital on its claim,
Issue          matches both the attending physician description and the information
Description:   contained in the medical record. Reviewers will validate MS-DRGs 955, 956,
               957, 958, 959, 963, 964 and 965 for principal and secondary diagnoses and
               procedures affecting or potentially affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 25, 2011
Dates of
               Rolling 36 month review look back
Service:
               Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99); PIM,
Issue          Chapter 6.5.3 DRG Validation Review; Uniform Hospital Discharge Data Set
References     (UHDDS) Reporting of Inpatient Data Elements, July 31, 1985; Federal
               Register (Vol.50, No. 147) Pages 31038-31040;




               MS-DRG Validation: MDC 25-Human Immunodeficiency Virus Infections
Issue Name:
               MSDRGs 969, 970, 974, 975, 976 and 977. (Medical Necessity Excluded)
Issue          A000662011
Number
               MS-DRG validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded by the hospital on its claim,
Issue          matches both the attending physician description and the information
Description:   contained in the medical record. Reviewers will validate MSDRGs 969, 970,
               974, 975, 976 and 977 for principal and secondary diagnoses and
               procedures affecting or potentially affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 25, 2011
Dates of
               Rolling 36 month review look back
Service:
               Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99); PIM,
Issue          Chapter 6.5.3 DRG Validation Review; Uniform Hospital Discharge Data Set
References     (UHDDS) Reporting of Inpatient Data Elements, July 31, 1985; Federal
               Register (Vol.50, No. 147) Pages 31038-31040;




               MS-DRG Validation: DRGs Associated with All MDCs MS-DRGs 984, 985,
Issue Name:
               986, 998 and 999 (Medical Necessity Excluded)
Issue
               A000672011
Number
               MS-DRG validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded by the hospital on its claim,
Issue          matches both the attending physician description and the information
Description:   contained in the medical record. Reviewers will validate MS-DRGs 984, 985,
               986, 987, 998 and 999 for principal and secondary diagnoses and
               procedures affecting or potentially affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE. DC. RI. CT. NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 25, 2011
Dates of
               Rolling 36 month review look back
Service:
               Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99); PIM,
Issue          Chapter 6.5.3 DRG Validation Review; Uniform Hospital Discharge Data Set
References     (UHDDS) Reporting of Inpatient Data Elements, July 31, 1985; Federal
               Register (Vol.50, No. 147) Pages 31038-31040;




Issue Name: Medical Necessity Review (MNR) for MS-DRG 101 Seizures without MCC
Issue
               A000352011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This will be of MS-DRG 101 Seizures
               without MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 3, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
Issue
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
References
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";




Issue Name: Medical Necessity Review (MNR) for MS-DRG 102 Headaches with MCC
Issue
               A000372011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 102
               Headaches with MCC.
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 3, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
Issue
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
References
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 114 Orbital Procedures
Issue Name:
               without CC/MCC
Issue
               A000382011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be for MS-DRG 114
               Orbital Procedures without CC/MCC.
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 3, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
Issue
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
References
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";




Issue Name: Medical Necessity Review (MNR) for MS-DRG 150 Epistaxis with MCC
Issue
               A000392011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be for MS-DRG 150
               Epistaxis with MCC.
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 3, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
Issue
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
References
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";




Issue Name: Medical Necessity Review (MNR) for MS-DRG 151 Epistaxis without MCC
Issue
               A000402011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 151
               Epistaxis without MCC.
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 3, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
Issue
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
References
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 154 Other Ear, Nose, Mouth,
Issue Name:
               & Throat Diagnoses with MCC
Issue
               A000412011
Number
Issue          Medicare pays for inpatient hospital services that are medically necessary for
Description:   the setting billed. Medical documentation will be reviewed to determine that
               services were medically necessary. This review will be of MS-DRG 154
               Other Ear, Nose, Mouth, & Throat Diagnoses with MCC.
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 3, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
Issue
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
References
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 156 Other Ear, Nose, Mouth
Issue Name:
               & Throat Diagnoses without CC/MCC.
Issue
               A000422011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 156
               Other Ear, Nose, Mouth & Throat Diagnoses without CC/MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 3, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
Issue
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
References
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 505 Foot Procedures without
Issue Name:
               CC/MCC
Issue
               A000432011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 505 Foot
               Procedures without CC/MCC.
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 3, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
Issue
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
References
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";




               Medical Necessity Review (MNR) for MS-DRG 090 Concussion without
Issue Name:
               CC/MCC
Issue
               A000342011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 090
               Concussion without CC/MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 2, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2;; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10;; Claims Processing Manual Chp 3,
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
Issue
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
References
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";




               Acute Inpatient Hospitalization - Musculoskeletal Disorders MS-DRGs: 542-
Issue Name:
               566
Issue
               A000152011
Number
               Medicare pays for inpatient hospital services that are medically necessary
Issue
               for the setting billed. Medical documentation will be reviewed to determine
Description:
               that services were medically necessary. MS-DRG: 542-566
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               CMS Publication 100-02 Medicare Claims Processing Manual:Chapter 1 §
               10; CMS Publication 100-02 Medicare Claims Processing Manual:Chapter 6
Issue
               § 10; CMS Publication 100-02 Medicare Claims Processing Manual:Chapter
References
               6 § 6.5.2; CMS Publication 100-02 Medicare Claims Processing
               Manual:Chapter 13 § 13.1; 13.1.1;




               Medical Necessity Review: Other Disorders of the Eye without MCC MS-
Issue Name:
               DRG 125
Issue
               A000182011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 125-
               Other Disorders of the Eye without MCC
Type of
               Medical Necessity Reviews
Review
State(s)       NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21),; Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2;; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10;; Claims Processing Manual Chp 3,
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
Issue
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
References
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";




               Acute Inpatient Hospitalization - Infections MS-DRG: 094-096;177-179;488-
Issue Name:
               489;539-41;602-603;689-690;856-858;862-9;871-872;977
Issue
               A000162011
Number
               Medicare pays for inpatient hospital services that are medically necessary
Issue          for the setting billed. Medical documentation will be reviewed to determine
Description:   that services were medically necessary. MS-DRG: 094-096;177-179;488-
               489;539-41;602-603;689-690;856-858;862-9;871-872;977”
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI,C T, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               CMS Publication 100-02 Medicare Claims Processing Manual: Chapter 1 §
               10; CMS Publication 100-02 Medicare Claims Processing Manual:Chapter 6
Issue
               § 10; CMS Publication 100-08 Medicare Program Integrity Manual:Chapter 6
References
               § 6.5.2; CMS Publication 100-08 Medicare Program Integrity
               Manual:Chapter 13 § 13.1; 13.1.1;




Issue Name: Medical Necessity Review: Disorders of the Eye with MCC MS-DRG 124
Issue
               A000172011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 124
               Disorders of the Eye with MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21),; Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2;; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10;; Claims Processing Manual Chp 3,
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
Issue
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
References
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";




Issue Name: Medical Necessity Review: Otitis Media & URI without MCC MS-DRG 153
Issue
               A000202011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This will be of MS-DRG 153-Otitis Media
               & URI without MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21; Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2;; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10;; Claims Processing Manual Chp 3,
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
Issue
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
References
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";
               Medical Necessity Review: Trauma to the Skin, Subcutaneous Tissue &
Issue Name:
               Breast without MCC MS-DRG 605
Issue
               A000212011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 605
               Trauma to the Skin, Subcutaneous Tissue & Breast without MCC.
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21),; Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2;; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10;; Claims Processing Manual Chp 3,
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
Issue
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
References
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";




               Medical Necessity Review : Mouth Procedures without CC/MCC MS-DRG
Issue Name:
               138
Issue
               A000192011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 138
               Mouth Procedures without CC/MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21),; Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2;; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10;; Claims Processing Manual Chp 3,
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
Issue
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
References
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";




               MS-DRG Validation: Transplants MS-DRGs 001, 005, 007, 008, 009 and 010
Issue Name:
               (Medical Necessity Excluded)
Issue
               A000222011
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate MS-DRGs 001, 005, 007, 008, 009, and 010 for principal and
               secondary diagnoses and procedures affecting or potentially affecting the
               MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG Report OAI-12-88-01010. ICD-9-CM Coding Manual (for dates of
Issue          service on claim); PIM 6.5.3 A-C DRG Validation Review; Uniform Hospital
References     Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31,
               1985, Federal Register (Vol. 50, No. 147), Pages 31038-31040;




               MS-DRG Validation: Respiratory Infections and Inflammations: MS-DRG 178
Issue Name:
               (Medical Necessity Excluded)
Issue
               A000232011
Number
               MS-DRG Validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded and reported by the
Issue          hospital on its claim, matches both the attending physician description and
Description:   the information contained in the beneficiary's medical record. Reviewers will
               validate MS-DRG 178 for principal and secondary diagnoses and procedures
               affecting or potentially affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review;
Issue          Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
References     Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 31038-
               31040;




               MS-DRG Validation: Biliary Tract, Heptobiliary and Pancreas Procedures:
Issue Name:    MS-DRGs: 408, 409, 410, 420, 421, 422, 423, 424 and 425 (Medical
               Necessity Excluded)
Issue
               A000242011
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate MS-DRGs 408, 409, 410, 420, 421, 422, 423, 424 and 425 for
               principal and secondary diagnoses and procedures affecting or potentially
               affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review,;
Issue          Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
References     Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 31038-
               31040;




               MS-DRG Validation: Aftercare, musculoskeletal system & connective tissue
Issue Name:
               MS-DRGs: 559, 560 and 561 (Medical Necessity Excluded)
Issue
               A000252011
Number
               MS-DRG Validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded and reported by the
Issue          hospital on its claim, matches both the attending physician description and
Description:   the information contained in the beneficiary's medical record. Reviewers will
               validate MS-DRGs 559, 560 and 561 for principal and secondary diagnoses
               and procedures affecting or potentially affecting the MS-DRG assignment.
Type of        DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review;
Issue          Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
References     Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 31038-
               31040;




               MS-DRG Validation: Breast Disorders. MS-DRGs 597, 598, 599, 600 and
Issue Name:
               601. (Medical Necessity Excluded)
Issue
               A000312011
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate MS-DRGs 597, 598, 599, 600 and 601 for principal and secondary
               diagnoses and procedures affecting or potentially affecting the MS-DRG
               assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review,;
Issue          Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
References     Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 31038-
               31040;




               MS-DRG Validation: Skin Disorders: MS-DRGs 593, 594, 595, 596, 603,
Issue Name:
               604, 605, 606 and 607 (Medical Necessity Excluded)
Issue
               A000262011
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate MS-DRGs 593, 594, 595, 596, 603, 604, 605, 606 and 607 for
               principal and secondary diagnoses and procedures affecting or potentially
               affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review;
Issue          Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
References     Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 31038-
               31040;




               MS-DRG Validation: Breast Procedures. MS-DRGs 582, 583, 584 and 585.
Issue Name:
               (Medical Necessity Excluded)
Issue
               A000322011
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate MS-DRGs 582, 583, 584, and 585 for principal and secondary
               diagnoses and procedures affecting or potentially affecting the MS-DRG
               assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review,;
Issue          Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
References     Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 31038-
               31040;




               MS-DRG Validation: Kidney Transplant-Urinary Stones: MS-DRGs 652, 692
Issue Name:
               and 694 (Medical Necessity Excluded)
Issue
               A000272011
Number
               MS-DRG Validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded and reported by the
Issue          hospital on its claim, matches both the attending physician description and
Description:   the information contained in the beneficiary's medical record. Reviewers will
               validate MS-DRGs 652, 692 and 694 for principal and secondary diagnoses
               and procedures affecting or potentially affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review,;
Issue          Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
References     Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 31038-
               31040;




               MS-DRG Validation: Male Reproductive System Procedures: MS-DRGs 707,
Issue Name:    708, 709, 710, 711, 712, 713, 714, 715, 716, 717 and 718 (Medical
               Necessity Excluded)
Issue
               A000282011
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate MS-DRGs 707, 708, 709, 710, 711, 712, 713, 714, 715, 716, 717
               and 718 for principal and secondary diagnoses and procedures affecting or
               potentially affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review,;
Issue          Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
References     Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 31038-
               31040;




               MS-DRG Validation: Male Reproductive System Disorders MS-DRGs 722,
Issue Name:
               723, 724, 725, 726, 727, 728. 729 and 730 (Medical Necessity Excluded)
Issue
               A000332011
Number
               MS-DRG Validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded and reported by the
Issue
               hospital on its claim, matches both the attending physician description and
Description:
               the information contained in the beneficiary's medical record. Reviewers will
               validate MS-DRGs 722, 723, 724, 725, 726, 727, 728. 729 and 730 for
               principal and secondary diagnoses and procedures affecting or potentially
               affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review,;
Issue          Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
References     Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 31038-
               31040;




               MS-DRG Validation: Female Reproductive System Disorders: MS-DRGs
Issue Name:
               754, 755, 756, 757, 758, 759, 760 and 761 (Medical Necessity Excluded)
Issue
               A000292011
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate MS-DRGs 754, 755, 756, 757, 758, 759, 760 and 761 for principal
               and secondary diagnoses and procedures affecting or potentially affecting
               the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review,;
Issue          Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
References     Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 31038-
               31040;




               MS-DRG Validation: Pregnancy, Childbirth & Puerperium: MS-DRGs 765,
Issue Name:    766, 767, 768, 769, 770, 774, 775, 776, 777, 778, 779, 780, 781, and 782
               (Medical Necessity Excluded)
Issue
               A000302011
Number
               MS-DRG Validation requires that diagnostic and procedural information and
Issue
               the discharge status of the beneficiary, as coded and reported by the
Description:
               hospital on its claim, matches both the attending physician description and
               the information contained in the beneficiary's medical record. Reviewers will
               validate MS-DRGs 765, 766, 767, 768, 769, 770, 774, 775, 776, 777, 778,
               779, 780, 781, and 782 for principal and secondary diagnoses and
               procedures affecting or potentially affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 1, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG Report OAI-12-88-01010; PIM 6.5.3 A-C DRG Validation Review,;
Issue          Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
References     Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 31038-
               31040;




            Medical Necessity: Acute Inpatient Admission Respiratory Conditions. The
Issue Name: MS DRGs affected are MS DRG 177-180, MS DRG 190-198 and MS DRG
            202-206.
Issue
               A000022011
Number
               RACs will review documentation to validate the medical necessity of short
               stay, uncomplicated admissions. Medicare only pays for inpatient hospital
               services that are medically necessary for the setting billed and that are
Issue
               coded correctly. Medical documentation will be reviewed to determine that
Description:
               the services were medically necessary and were billed correctly. The MS
               DRGs affected are MS DRG 177-180, MS DRG 190-198 and MS DRG 202-
               206.
Type of
               Medical Necessity Reviews
Review
State(s)
               PA, DC, NJ, DE, NY, CT, VT, ME, MA, NH, RI
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: February 24, 2011
Dates of
               Rolling 36 month review look back
Service:
               RAC Demonstration Evaluation; Medicare Benefit Policy Manual Chapter 1 -
               Inpatient Hospital Services Covered Under Part A; Medicare Benefit Policy
Issue          Manual Chapter 6 - Hospital Services Covered Under Part B; Medicare
References     Program Integrity Manual Chapter 6 - Intermediary MR Guidelines for
               Specific Services; Medicare Program Integrity Manual Chapter 13 – Local
               Coverage Determinations;




Issue Name: Incorrect Bilateral Billing for Codes with Bilateral Indicator 3
Issue
               A001312010
Number
             Overpayments associated with providers incorrectly billing services with
Issue        bilateral indicator 3 (100% payable for each side) on multiple lines; once with
Description: modifier 50 (resulting in 200% payment) and once without modifier 50
             (resulting in 100% payment), resulting in a 300% total payment.
Type of
               Automated
Review
State(s)
               DC, CT, DE, MD, NJ, NY, PA
Affected:
Providers
               Professional Services
Affected:
Date Posted: February 18, 2011
Dates of
               Rolling 36 month review look back
Service:
               CMS Medicare Physician Fee Schedule 2007-2010, RVUPUF File, Bilateral
               Indicator 3 Description. See Appendix E; CMS Internet Only Manual 100-04
               (Medicare Claims Processing Manual), Chapter 12 (Physician/Nonphysician
               Practitioner Services), Section 40.7, Subsection B and C. See Appendix F.;
Issue          CMS Internet Only Manual 100-04 (Medicare Claims Processing Manual),
References     Chapter 23 (Fee Schedule Administration and Coding Requirements),
               Addendum - MPFSDB Record Layouts. See Appendix G; CMS Internet Only
               Manual, 100-04 (Medicare Claims Processing Manual), Chapter 4 (Part B
               Hospital), Subsection 20.6.2. See Appendix H; Highmark Medicare Services,
               Medicare A/B Reference Manual, Chapter 22, section 22.1.e.1.;




Issue Name:       Duplicate Claims - DME
Issue Number      A000772010
Issue             Identification of overpayments made on duplicate claims by DME
Description:      suppliers.
Type of Review Automated
State(s)
                  NY, NJ, CT, DE, MA, MD, ME, NH, PA, RI, VT
Affected:
Providers
                  DME
Affected:
Date Posted:      February 11, 2011
Dates of
                  Rolling 36 month review look back
Service:
Issue             IOM 100-4 (Medicare Claims Processing Manual), Chapter 1 (General
References        Billing Requirements), Section 120, effective 7/1/2005;




Issue Name:    Medically Unlikely Units (MUE) Table
Issue
               A000782010
Number
               Identification of overpayments associated with providers billing the same
Issue
               code in excess of units of service for the same beneficiary on the same date
Description:
               of service as stipulated in CMS MUE Table.
Type of
               Automated
Review
State(s)       CT, NY, PA
Affected:
Providers
               Outpatient Hospitals
Affected:
Date Posted: February 11, 2011
Dates of
               Rolling 36 month review look back
Service:
               National Correct Coding Policy Manual, Chapter 1 General Correct Coding
               Policies, Section V (NCCI V12.3 and forward).; National Correct Coding
Issue          Initiative, Medically Unlikely Edits, Outpatient Facility Services MUE Table;
References     CMS Manual System, Pub 100-08, Chapter 3, Subsection 3.6; CMS Manual
               System, Pub 100-20 One-Time Notification, Transmittal 617, CR 6712,
               Section I, Subsection B;




Issue Name:     Add-On Codes Paid without a Paid Required Primary Procedure
Issue Number A000792010
Issue           Claims overpaid for add-on codes when the required primary procedure is
Description:    not billed on any claim (same or different) for the same date of service.
Type of
                Automated
Review
State(s)
                PA, NY, CT
Affected:
Providers
                Outpatient Hospitals
Affected:
Date Posted:    February 11, 2011
Dates of
                Rolling 36 month review look back
Service:
                Internet Only Manual 100-04, Medicare Claims Processing Manual,
Issue
                Chapter 12, Physicians/Non-Physician Practitioners, Section 30,
References
                Subsection D, revision effective 10/1/2003;




Issue Name: Evaluation and Management Services with Allergy Services
Issue
               A000902010
Number
               Identification of overpayments made for Evaluation and Management
Issue
               services billed without modifier 25 on the same date of service as allergy
Description:
               testing or allergen immunotherapy.
Type of
               Automated
Review
State(s)
               NY
Affected:
Providers
               Professional Services
Affected:
Date Posted: February 11, 2011
Dates of
               Rolling 36 month review look back
Service:
Issue          National Correct Coding Initiative Policy Manual for Medicare Services,
References     Versions 12.3 and higher, Chapter 11, Section J.3 (version 12.3 only) and
               Section K.3 (versions 13.3 and higher; Internet Only Manual 100-04
               (Medicare Claims Processing), Chapter 12 (Physician/Non-Physician
               Practitioners), Section 200, Subsection C, revision 504, issued 3/11/2005.
               Please see Appendix F.; MAC Part B - J13 - LCD L28451 Allergy
               Immunotherapy, effective 1/1/2009 (Replaced LCD L28138) for New York
               and Connecticut. Please see appendix G.; MAC Part B - J13 - Article
               A47997 (Supplemental to LCD L28451), effective 1/1/2009 (Replaced Article
               A47570) for New York and Connecticut. Please see appendix H.;




Issue Name: Incorrect Use of Modifier 51 with CPT Code 51797
Issue
               A001032010
Number
               Identification of underpayments associated with providers billing CPT code
               51797 with modifier 51. CPT code 51797 is an add-on code that has a
Issue
               Multiple Procedure Indicator of 0 (No payment adjustment rules for multiple
Description:
               procedure reduction apply) and is, therefore, not subject to a payment
               reduction. Audit time period from 1/1/08 - 6/30/08.
Type of
               Automated
Review
State(s)
               NY
Affected:
Providers
               Professional Services
Affected:
Date Posted: February 11, 2011
Dates of
               Rolling 36 month review look back
Service:
               CMS National Physician Fee Schedule Relative Value File Calendar Year for
               2008, 2009 and 2010; CMS Transmittal R1528CP, CR 6087, effective May
Issue
               30, 2008, changes retroactive to January 1, 2008; CMS Internet Only Manual
References
               100-04 (Medicare Carriers Processing Manual), Chapter 12
               (Physician/Nonphysician Practitioner Services), subsection 40.6.C;




Issue Name:    Anesthesia Care and Packaged Evaluation Management Services
Issue
               A001052010
Number
               Identification of overpayments associated with evaluation and management
               services billed the day prior to or day of anesthesia services by an
Issue          anesthesiologist. 1) E/M services (as specifically defined in the IOM) billed
Description:   the day prior to or day of anesthesia services without modifiers 24, 25, or 57.
               2) E/M services billed the same day as 01996 without modifiers 24, 25, or
               57.
Type of
               Automated
Review
State(s)
               NY
Affected:
Providers
               Professional Services
Affected:
Date Posted: February 11, 2011
Dates of       Rolling 36 month review look back
Service:
               National Correct Coding Initiative Policy Manual, v12.3, v13.3, v14.3,
Issue
               v14.3.1, v15.3, Chapter 2, § A, B.1, B.3; CMS Publication 100-04, Chapter
References
               12 § 50.C & F, 1/1/1998;




               Radiologists billing Evaluation & Management Services with Diagnostic
Issue Name:
               Mammography Services
Issue
               A001062010
Number
               Identification of overpayments associated with radiologists billing evaluation
Issue
               and management services on the same date of service as diganostic
Description:
               mammography services.
Type of
               Automated
Review
State(s)
               NY, CT
Affected:
Providers
               Professional Services
Affected:
Date Posted: February 11, 2011
Dates of
               Rolling 36 month review look back
Service:
               CMS MAC J-13, National Government Services (NGS), Part B, LCD
               (L26890), original determination effective date of 7/1/2008, revision effective
Issue          date of 4/1/2010, applies to New York and Connecticut and replaced LCD
References     (L3500); CMS MAC J-13, Healthnow New York, Inc., LCD (L3761), original
               determination effective date of 2/1/2000, revision effective date of 1/1/2007,
               retired effective 8/31/2008, applies to New York only.;




               Verteporfin & Ocular Photodynamic Therapy without Fluoroscein
Issue Name:
               Angiography
Issue
               A001082010
Number
               Identification of overpayments associated with providers billing for
Issue          Verteporfin (J3396) and Ocular Photodynamic Therapy (67221-67225) in the
Description:   absence of flourescein angiography (92235) or indocyanine-green
               angiography (92240) performed prior to each treatment.
Type of
               Automated
Review
State(s)
               NY, PA, NJ, CT, DE, MD, DC
Affected:
Providers
               Professional Services
Affected:
Date Posted: February 11, 2011
Dates of
               Rolling 36 month review look back
Service:
               CMS Internet Only Manual 100-03, Chapter 1, Part1, Sections 80.2 - 80.3.1.,
Issue
               effective 10/3/2003. See Appendix E; CMS National Coverage
References
               Determination for Ocular Photodynamic Therapy (OPT), 80.2, version 2,
                effective 4/1/2004. See Appendix F; CMS Transmittal 9, CR 3191, posted
                4/1/2004. See Appendix G;




Issue Name: Wheelchair Options and Accessories Invalid Claims Submission
Issue
               A001202010
Number
Issue        Identification of paid wheelchair options and accessories that are invalid for
Description: submission to Medicare
Type of
               Automated
Review
State(s)
               NJ, PA
Affected:
Providers
               DME
Affected:
Date Posted: February 11, 2011
Dates of
               Rolling 36 month review look back
Service:
               CMS DME MAC, Jurisdiction A, Policy Article (A19829) for Wheelchair
               Options/Accessories, original effective date of 7/1/2004 and subsequent
               revisions; DME MAC, Jurisdiction A, LCD (L11473) for Wheelchair
Issue          Options/Accessories, original effective date of 10/1/1993, revision date of
References     6/1/2007; CMS, Internet-Only Manuals (IOM), National Coverage
               Determination (NCD) Manual, Pub. 100-03, Chapter 1, Part 4, Sections
               280.1 and 280.3, (revision effective 5/5/05; implementation of 7/5/05), refer
               to coverage provisions for Mobility Assistive Equipment (MAE);




Issue Name:     Pulmonary Diagnostic Procedures and Evaluation & Management Services
Issue Number A001262010
                Identification of overpayments associated with limited evaluation and
Issue
                management services (99211-99212) billed without modifier 25 on the
Description:
                same date of service as a pulmonary diagnostic procedure (94010-94799)
Type of
                Automated
Review
State(s)
                CT, DC, DE, MD, NJ, NY, PA
Affected:
Providers
                Professional Services
Affected:
Date Posted:    February 11, 2011
Dates of
                Rolling 36 month review look back
Service:
Issue           National Correct Coding Initiative Policy Manual, v13.3; v14.3; v15.3
References      Chapter 11, § J.2;




Issue Name: ECGs with Cardiac Catheterization Procedures
Issue          A001302010
Number
               An overpayment may exist when outpatient hospital providers bill separately
Issue          for ECGs performed the same date of service as cardiac catherization
Description:   procedures. ECGs unrelated (e.g. peformed prior to or after) the cardiac
               catherization should be billed with modifier 59.
Type of
               Automated
Review
State(s)
               DC, CT, DE, MD, NJ, NY, PA
Affected:
Providers
               Outpatient Hospitals
Affected:
Date Posted: February 11, 2011
Dates of
               Rolling 36 month review look back
Service:
               National Correct Coding Initiative Policy Manual, Chapter 11, Section I,
               Subsection 2, 13, and 14, Manual Version 13.3 (Effective 10/1/2007);
               National Correct Coding Initiative Policy Manual, Chapter 11 (Medicine,
Issue          Evaluation and Management Services), Section I, Subsections 3, 15, and 16.
References     Manual Version 14.3 (Effective 10/1/2008); National Correct Coding Initiative
               Policy Manual, Chapter 11, Section I, Subsections3, 12, and 13, Manual
               Version 15.3 (Effective 10/1/2009); National Correct Coding Initiative Edits -
               Outpatient Hospital;




            Medical Necessity Review (MNR) to establish whether it was medically
Issue Name: necessary to receive care in an inpatient setting- MS-DRG 641- Nutritional
            and Misc. Metabolic Disorders w/o MCC
Issue
               A000102011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS DRG 641 --
               Nutritional and Misc. Metabolic Disorders w/o MCC.
Type of
               Medical Necessity Reviews
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: February 10, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
Issue
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
References
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";




            Medical Necessity Review (MNR) to establish whether it was medically
Issue Name: necessary to receive care in an inpatient setting- Red Blood Cell Disorders
            w/o MCC
Issue
               A000112011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS DRG 812 --
               Red Blood Cell Disorders w/o MCC.
Type of
               Medical Necessity Reviews
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: February 10, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
Issue
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
References
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";




            Medical Necessity Review (MNR) to establish whether it ws medically
Issue Name: necessary to receive care in an inpatient setting-Cervical Spinal Fusion w/o
            cc/mcc
Issue
               A000132011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS DRG 473 --
               Cervical Spinal Fusion w/o cc/mcc.
Type of
               Medical Necessity Reviews
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: February 10, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
Issue
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
References
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";




Issue Name: Air-fluidized Bed
Issue
               A001332010
Number
               Patients may have been provided a Group 3 support surface but did not
Issue          meet the clinical criteria for coverge. The medical review will determine
Description:   whether this level of treatment, utilizing an air-fluidizing bed (E0194), was
               reasonable and necessary based on the patient's condition.
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, MD, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               DME
Affected:
Date Posted: February 10, 2011
Dates of
               Rolling 36 month review look back
Service:
               Internet Only Manuals (IOMs), Publication 100-02, Medicare Benefit Policy
               Manual, Chapter 15, Section 110, Durable Medical Equipment – General;
               Internet Only Manuals (IOMs), Publication 100-08, Medicare Program
               Integrity Manual, Chapter 5, Section 5.7, Documentation in the Patient’s
Issue          Medical Record; Internet Only Manual (IOMs), Publication 100-03 National
References     Coverage Determination (NCD) Manual: Chapter 1, Part 4, Section 280.8,
               Air-Fluidized Beds; Local Coverage Determination NHIC Medicare Services,
               (L5069) - LCD for Group 3 Pressure Reducing Support Surface and attached
               Article (A37217); Office of Inspector General OEI-02-95-00370, June 1997 –
               Pressure Reducing Support Surfaces;




Issue Name: Pneumatic Compression Device
Issue
               A001342010
Number
Issue          Medical review will determine whether this level of treatment, utilizing device
Description:   (E0652), was appropriate.
Type of        Medical Necessity Reviews
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT, MD
Affected:
Providers
               DME
Affected:
Date Posted: February 10, 2011
Dates of
               Rolling 36 month review look back
Service:
               Internet Only Manuals (IOMs), Publication 100-02, Medicare Benefit Policy
               Manual, Chapter 15, Section 110, Durable Medical Equipment – General;
               Internet Only Manuals (IOMs), Publication 100-08, Medicare Program
               Integrity Manual, Chapter 5, Section 5.7, Documentation in the Patient’s
               Medical Record; Internet Only Manual (IOMs), Publication 100-03 National
Issue
               Coverage Determination (NCD) Manual: Chapter 1, Part 4, 280.6, Pneumatic
References
               Compression Devices; Transmittal R151, Change Request 1944 – Revision
               to Pneumatic Compression Devices; Local Coverage Determination NHIC
               Medicare Services, (L11503) - LCD for Pneumatic Compression Devices;
               Office of Inspector General (OIG) Report OEI-04-97-00130, July 1998 –
               Medicare Allowances for Lymphedema Pumps;




Issue Name: Power Wheelchairs (PWCs), Group 2
Issue
               A001352010
Number
               Group 2 Power Wheelchairs, HCPCS Codes K0823, K0825, K0827, K0829,
               may have been provided to patients that did not meet the medical necessity
               criteria for coverage for the power wheelchair (PWC) supplied. The review
Issue
               will determine if PWC was reasonable and necessary for the patient’s
Description:
               condition or if the patient should have received an alternative treatment
               which may be better suited based on the documentation in the medical
               record.
Type of
               Medical Necessity Reviews
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               DME
Affected:
Date Posted: February 10, 2011
Dates of
               Rolling 36 month review look back
Service:
               Internet Only Manuals (IOMs), Publication 100-02, Medicare Benefit Policy
               Manual, Chapter 15, Section 110, Durable Medical Equipment – General;
               Internet Only Manuals (IOMs), Publication 100-08, Medicare Program
               Integrity Manual, Chapter 5, Section 5.9.2, Evidence of Medical Necessity:
               Wheelchair and Power Operated Vehicle (POV) Claims; Internet Only
               Manual (IOMs), Publication 100-03 National Coverage Determination (NCD)
Issue          Manual: Chapter 1, Part 4, Section 280.3, Mobility Assisted Equipment;
References     Local Coverage Determination NHIC Medicare Services, (L21271) - LCD for
               Power Mobility Devices and attached NHIC Medicare Services Article,
               (A36239) – Power Mobility Devices; Office of Inspector General (OIG)
               Report OEI-04-07-00401, December 2009 – Medicare Power Wheelchair
               Claims Frequently Did Not Meet Documentation Requirements; Office of
               Inspector General (OIG) Report OEI-04-07-00403, December 2007 –
               Miscoded Claims for Power Wheelchairs in the Medicare Program;
            MS-DRG Validation: Joint Procedures(2) 461, 480, 482, 483, 484, 485, 487,
Issue Name: 489, 492, 493, 494, 503, 504, 505, 506, 507, 508, 509, 510, 511, 512, 513,
            514, 535, 536, and 906 (Medical Necessity Excluded)
Issue
               A001002010
Number
               MS-DRG Validation for MS-DRGs 461, 480, 482, 483, 484, 485, 487, 489,
               492, 493, 494, 503, 504, 505, 506, 507, 508, 509, 510, 511, 512, 513, 514,
               535, 536, and 906 MS-DRG validation requires that diagnostic and
               procedural information and the discharge status of the beneficiary, as coded
Issue
               on the hospital claim, matches both the attending physician description and
Description:
               the information contained in the medical record. Reviewers will validate MS-
               DRGs 461,480, 482, 483, 484, 485, 487, 489, 492, 493, 494, 503, 504, 505,
               506, 507, 508, 509, 510, 511, 512, 513, 514, 535, 536 and 906 for diagnoses
               and procedures affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: February 10, 2011
Dates of
               Rolling 36 month review look back
Service:
Issue          PIM, Chapter 6.5.3 - Section A-C - Monitoring the Accuracy of Hospital
References     Coding (OEI-01-98-00420; 1/99) DRG Validation Review;




Issue Name:    Bilateral In Nature Procedures
Issue Number A001362010
Issue          Overpayment associated to payment for procedures that are bilateral in
Description:   nature that exceed the price of a single unit of service.
Type of
               Automated
Review
State(s)
               NJ, NY, DC, MD, CT, PA, DE
Affected:
Providers
               Professional Services
Affected:
Date Posted:   February 10, 2011
Dates of
               Rolling 36 month review look back
Service:
               CMS Medicare Physician Fee Schedule, Bilateral Indicator 2 (150%
Issue          payment adjustment does not apply).; CMS Internet Only Manual 100-04
References     (Medicare Claims Processing Manual), Chapter 12 (Physician/Non-
               Physician Practitioners), subsection 40.7;




Issue Name:    Colonoscopy - Excess Units
Issue
               A000372009
Number
               The CPT code descriptors for certain colonoscopy codes includes language
               that indicates the codes should only be billed once even if multiple sites are
Issue
               treated using the same technique for the same beneficiary and same date of
Description:
               service. This issue identifies overpayments associated to providers billing
               these colonscopy services with more than one unit of service.
Type of
               Automated
Review
State(s)
               NY
Affected:
Providers
               Outpatient Hospitals
Affected:
Date Posted: February 10, 2011
Dates of
               Rolling 36 month review look back
Service:
               CMS RAC Demonstration Evaluation Report, June 2008, page 52; CMS
Issue          Medically Unlikely Edits, codes 45378, 45380, 45381, 45383, 45384, 45385,
References     45386, 45392; NCCI Policy Manual for Medicare Services, Version 15.3,
               Chapter 1, Section V;




Issue Name:    Initial Infusion Services
Issue Number A000762010
               Identification of overpayments associated with providers billing 'initial'
Issue          intravenous infusion (90765 and 96365), and subcutaneous infusion (90769
Description:   and 96369), with more than one unit of service by the same provider for the
               same beneficiary on the same date of service.
Type of
               Automated
Review
State(s)
               NY, CT, MD, NJ, PA
Affected:
Providers
               Outpatient Hospitals
Affected:
Date Posted:   February 10, 2011
Dates of
               Rolling 36 month review look back
Service:
               CMS Medicare Claims Processing Manual, Chapter 4, Part B Hospital,
Issue
               Section 230.2; CMS Hosptial Outpatient PPS, OPPS Guidance for CY 2006;
References
               HighMark Medicare Services, Article (A47797), revision date of 12.12.2008;




Issue Name:    Outpatient Hospital - E/M Code with Status S or T Code
Issue Number A000682010
               An overpayment exists when a provider bills an evaluation and
Issue          management code, assigned with status V, without modifier 25 on the same
Description:   date of service as a significant medical or surgical code, status S and T
               respectively.
Type of
               Automated
Review
State(s)
                CT, PA, NY
Affected:
Providers
                Outpatient Hospitals
Affected:
Date Posted:    February 10, 2011
Dates of
                Rolling 36 month review look back
Service:
                CMS Integrated OCE Specifications, versions 8.3 and higher, OCE edit 21,
Issue
                implementation of edit was pre-2004. See CMS transmittal 1872, CR 6761
References
                for specifications for current version; CMS Detailed OPPS Program Edits;




            Medical Necessity Review (MNR) to establish whether it was medically
Issue Name: necessary to receive care in an inpatient setting for MS-DRG 491-Back and
            Neck Procedures Except Spinal Fusion without CC/MCC
Issue
               A000092011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 491-Back
               and Neck Procedures Except Spinal Fusion without CC/MCC.
Type of
               Medical Necessity Reviews
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: February 9, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
               L27548; Pepper Report "Top 20 DRGs for One-day Stays for Short-term
Issue
               Acute Care Hospitals"; Medicare Inpatient Fact Sheet; OIG Report A-01-10-
References
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";




               Medical Necessity: Acute Inpatient Admission Neurological Disorders MS-
Issue Name:
               DRG's 068, 069, 070, 071, 072, 073, 074, 103, 312
Issue
               A001372010
Number
               RACs will review documentation to validate the medical necessity of short
Issue
               stay, uncomplicated admissions. Medicare only pays for inpatient hospital
Description:
               services that are medically necessary for the setting billed and that are
               coded correctly. Medical documentation will be reviewed to determine that
               the services were medically necessary and were billed correctly for MS-
               DRG's, 068, 069, 070, 071, 072, 073, 074, 103 and 312.
Type of
               Medical Necessity Reviews
Review
State(s)
               PA, DC, NJ, DE, NY, CT, VT, ME, MA, NH, RI
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: February 9, 2011
Dates of
               Rolling 36 month review look back
Service:
               Medicare Program Integrity Manual Chapter 13 – Local Coverage
               Determinations; Medicare Program Integrity Manual Chapter 6 - Intermediary
               MR Guidelines for Specific Services; Medicare Benefit Policy Manual
Issue
               Chapter 6 - Hospital Services Covered Under Part B; Medicare Benefit
References
               Policy Manual Chapter 1 - Inpatient Hospital Services Covered Under Part A;
               THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM:
               An Evaluation of the 3-Year Demonstration;




            Medical Necessity Review (MNR) to establish whether it was medically
Issue Name: necessary to receive care in an inpatient setting- Extracranial Procedures
            without CC/MCC
Issue
               A000042011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. MS-DRG 039 Extracranial Procedures
               without CC/MCC
Type of
               Medical Necessity Reviews
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT; excluding Maryland (MD)
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: February 9, 2011
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10; Claims Processing Manual Chp 3,
               Section 40.2.2; Local Coverage Determination Highmark Medicare Services
               L27548; Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for
Issue
               One-day Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-
References
               01000 July 2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG
               Report 09-88-00880 "National DRG Validation Study Unnecessary
               Admissions to Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA
               PA Regional Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG
               Report oai-05-88-00730 "National DRG Validation Study: Short
               Hospitalizations";
               MS-DRG Validation: Skin Graft Connective Tissues Disorder 477, 478, 479,
Issue Name:    515, 516, 517, 576, 577, 578, 579, 580, 581, 622, 623, 624, 904 and 905
               (Medical Necessity Excluded)
Issue
               A000952010
Number
               MS-DRG Validation for MS-DRGs 477, 478, 479, 515, 516, 517, 576, 577,
               578, 579, 580, 581, 622, 623, 624, 904 and 905 MS-DRG validation requires
               that diagnostic and procedural information and the discharge status of the
Issue          beneficiary, as coded on the hospital claim, matches both the attending
Description:   physician description and the information contained in the medical record.
               Reviewers will validate MS-DRGs 477, 478, 479, 515, 516, 517, 576, 577,
               578, 579, 580, 581, 622, 623, 624, 904 and 905 for diagnoses and
               procedures affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: January 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG “National DRG Validation Study Special Report on Coding Accuracy”
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
References
               UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040;;




               MS-DRG Validation: Female Reproductive Disorders MS DRGs 734, 735,
Issue Name:    736, 737, 738, 739, 740, 741, 742, 743, 744, 745, 746, 747, 748, 749 and
               750 (Medical Necessity Excluded)
Issue
               A000982010
Number
               MS-DRG Validation for MS-DRGs 734 - 750 MS-DRG validation requires
               that diagnostic and procedural information and the discharge status of the
               beneficiary, as coded on the hospital claim, matches both the attending
Issue
               physician description and the information contained in the medical record.
Description:
               Reviewers will validate MS-DRGs 734, 735, 736, 737, 738, 739, 740, 741,
               742, 743, 744, 745, 746, 747, 748, 749 and 750 for diagnoses and
               procedures affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: January 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG “National DRG Validation Study Special Report on Coding Accuracy”
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
References
               UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040;;




               MS-DRG Validation: Disorders and Procedures of the Eye (Medical
Issue Name:
               Necessity Excluded)
Issue
               A001252010
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate MS-DRGs113, 114, 115, 116, 117, 121, 122, 123, 124 and 125 for
               principal and secondary diagnoses and procedures affecting or potentially
               affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: January 27, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG “National DRG Validation Study Special Report on Coding Accuracy”
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
References
               UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040;;




               MS-DRG Validation: Major Cardiovascular Procedures (Medical Necessity
Issue Name:
               Excluded)
Issue
               A000532010
Number
               MS-DRG Validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded and reported by the
Issue          hospital on its claim, matches both the attending physician description and
Description:   the information contained in the beneficiary's medical record. Reviewers will
               validate for MS-DRG 238; principal diagnosis, secondary diagnoses, and
               procedures affecting or potentially affecting the MS-DRG.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: January 14, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG “National DRG Validation Study Special Report on Coding Accuracy”
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
References
               UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040;;




               MS-DRG Validation: CAD versus Unstable Angina (Medical Necessity
Issue Name:
               Excluded)
Issue
               A000542010
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate for MS-DRG 311; principal diagnosis, secondary diagnosis and
               procedures that affect or can potentially affect the MS-DRG assignment, for
               the MS-DRG.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: January 14, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG “National DRG Validation Study Special Report on Coding Accuracy”
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
References
               UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040;;




               MS-DRG Validation: Infectious and Parasitic Diseases (MDC 18) MS-DRGs
Issue Name:    853, 854, 855, 856, 857, 858, 862, 863, 864, 865, 866, 867, 868, 869, 871
               and 872 (Medical Necessity Excluded)
Issue
               A001112010
Number
               MS-DRG Validation for MS-DRGs 853, 854, 855, 856, 857, 858, 862, 863,
               864, 865, 866, 867, 868, 869, 871 and 872 MS-DRG validation requires that
               diagnostic and procedural information and the discharge status of the
Issue          beneficiary, as coded on the hospital claim, matches both the attending
Description:   physician description and the information contained in the medical record.
               Reviewers will validate MS-DRGs 853, 854, 855, 856, 857, 858, 862, 863,
               864, 865, 866, 867, 868, 869, 871 and 872 for diagnoses and procedures
               affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)       DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: January 14, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG “National DRG Validation Study Special Report on Coding Accuracy”
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
References
               UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040;;




               MS-DRG Validation: Diseases and Disorders of the Nervous System (MDC
Issue Name:
               1) MS-DRGs 075, 076, 094, 095 and 096 (Medical Necessity Excluded)
Issue
               A001122010
Number
               MS-DRG Validation for MS-DRGs 075, 076, 094, 095 and 096 MS-DRG
               validation requires that diagnostic and procedural information and the
Issue          discharge status of the beneficiary, as coded on the hospital claim, matches
Description:   both the attending physician description and the information contained in the
               medical record. Reviewers will validate MS-DRGs 075, 076, 094, 095 and
               096 for diagnoses and procedures affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: January 14, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG “National DRG Validation Study Special Report on Coding Accuracy”
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
References
               UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040;;




            MS-DRG Validation: Disorders Related to Injuries/Toxicity MS-DRGs 906,
Issue Name: 913, 914, 915, 916, 917, 918, 919, 920, 921, 922 and 923 (Medical
            Necessity Excluded)
Issue
               A001132010
Number
               MS-DRG Validation for MS-DRGs 906, 913, 914, 915, 916, 917, 918, 919,
               920, 921, 922 and 923 MS-DRG validation requires that diagnostic and
               procedural information and the discharge status of the beneficiary, as coded
Issue
               on the hospital claim, matches both the attending physician description and
Description:
               the information contained in the medical record. Reviewers will validate MS-
               DRGs 906, 913, 914, 915, 916, 917, 918, 919, 920, 921, 922 and 923 for
               diagnoses and procedures affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: January 14, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG “National DRG Validation Study Special Report on Coding Accuracy”
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
References
               UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040;;




               MS-DRG Validation: Diseases and Disorders of the Ear, Nose, Mouth and
Issue Name:
               Throat (Medical Necessity Excluded)
Issue
               A001242010
Number
               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
Issue          the information contained in the beneficiary's medical record. Reviewers will
Description:   validate MS-DRGs129, 130, 131, 132, 133, 134, 135, 136, 137, 138, 139,
               146, 147, 148, 149, 150, 151, 152, 153, 154, 155, 156, 157, 158 and 159 for
               principal and secondary diagnoses and procedures affecting or potentially
               affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: January 14, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG “National DRG Validation Study Special Report on Coding Accuracy”
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
References
               UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040;;




               MS-DRG Validation: Endocrine, Nutritional & Metabolic Disorders MS-DRGs
Issue Name:
               614, 615, 625, 626, 627, 628, 629 and 630 (Medical Necessity Excluded)
Issue
               A001012010
Number
             MS-DRG Validation for MS-DRGs 614,615,625,626,627,628,629 and 630
Issue
             MS-DRG validation requires that diagnostic and procedural information and
Description:
             the discharge status of the beneficiary, as coded on the hospital claim,
               matches both the attending physician description and the information
               contained in the medical record. Reviewers will validate MS-DRGs 614, 615,
               625, 626, 627, 628, 629 and 630 for diagnoses and procedures affecting the
               MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: January 14, 2011
Dates of
               Rolling 36 month review look back
Service:
               OIG “National DRG Validation Study Special Report on Coding Accuracy”
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
References
               UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040;;




               MS-DRG Validation: Major Gastrointestinal Disorders and Peritoneal
Issue Name:
               Infections (Medical Necessity Excluded)
Issue
               A000862010
Number
               MS-DRG Validation for MS-DRGs 371, 372, 373. Reviewers will validate the
Issue
               principal diagnosis, secondary diagnosis and procedures that affect or can
Description:
               potentially affect the MS-DRG assignment, for the MS-DRGs listed.
Type of
               DRG Validation
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040.;




               MS-DRG Validation: O.R. Procedures for Obesity (Medical Necessity
Issue Name:
               Excluded)
Issue
               A000722010
Number
               MS-DRG Validation requires that diagnostic and procedural information and
Issue          the discharge status of the beneficiary, as coded and reported by the
Description:   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 619, 620, 621; principal diagnosis, secondary
               diagnosis and procedures that affect or can potentially affect the MS-DRG.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040.;




Issue Name:    MS-DRG Validation: Metastasis (Medical Necessity Excluded)
Issue
               A000622010
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate for MS-DRGs 820, 821, 822, 823, 824, 825, 840,841, 842: principal
               diagnosis, secondary diagnosis and procedures that affect or can potentially
               affect the MS-DRG assignment, for the MS-DRGs listed.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040.;




               MS-DRG Validation: Other OR Procedures for Injuries (Medical Necessity
Issue Name:
               Excluded)
Issue
               A000642010
Number
               MS-DRG Validation requires that diagnostic and procedural information and
Issue
               the discharge status of the beneficiary, as coded and reported by the
Description:
               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 907, 908, 909; principal diagnosis, secondary
               diagnoses, and procedures affecting or potentially affecting the MS-DRG.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040.;




Issue Name:    MS-DRG Validation: Spinal Fusion (Medical Necessity Excluded)
Issue
               A000652010
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate for MS-DRGs 453, 454, 455, 456, 457, 458, 459, 460; principal
               diagnosis, secondary diagnosis and procedures that affect or can potentially
               affect the MS-DRG .
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040.;




Issue Name:    MS-DRG Validation: Soft Tissue Procedures (Medical Necessity Excluded)
Issue
               A000752010
Number
               MS-DRG Validation requires that diagnostic and procedural information and
Issue
               the discharge status of the beneficiary, as coded and reported by the
Description:
               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 500, 501, 502; principal diagnosis, secondary
               diagnosis and procedures that affect or can potentially affect the MS-DRG.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040.;




               MS-DRG Validation: Stomach, Esophageal and Duodenal Procedures
Issue Name:
               (Medical Necessity Excluded)
Issue
               A000802010
Number
               MS-DRG Validation for MS-DRGs 326, 327, 328. Reviewers will validate the
Issue
               principal diagnosis, secondary diagnosis and procedures that affect or can
Description:
               potentially affect the MS-DRG assignment, for the MS-DRGs listed.
Type of
               DRG Validation
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040.;




               MS-DRG Validation: Pancreas, Liver and Shunt Procedures (Medical
Issue Name:
               Necessity Excluded)
Issue
               A000832010
Number
               MS-DRG Validation for MS-DRGs 405, 406, 407. Reviewers will validate the
Issue
               principal diagnosis, secondary diagnosis and procedures that affect or can
Description:
               potentially affect the MS-DRG assignment, for the MS-DRGs listed.
Type of        DRG Validation
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040.;




               MS-DRG Validation: Other Respiratory System O.R. Procedures (Medical
Issue Name:
               Necessity Excluded)
Issue
               A000842010
Number
               MS-DRG Validation for MS-DRGs 166, 167, 168, 264. Reviewers will
Issue          validate the principal diagnosis, secondary diagnosis and procedures that
Description:   affect or can potentially affect the MS-DRG assignment, for the MS-DRGs
               listed. (MS-DRG 264 added 8-6-10 CMS pre-approved)
Type of
               DRG Validation
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040.;




               MS-DRG Validation: Other Digestive System O.R. Procedures (Medical
Issue Name:
               Necessity Excluded)
Issue
               A000852010
Number
               MS-DRG Validation for MS-DRGs 356, 357, 358. Reviewers will validate the
Issue
               principal diagnosis, secondary diagnosis and procedures that affect or can
Description:
               potentially affect the MS-DRG assignment, for the MS-DRGs listed.
Type of
               DRG Validation
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040.;




               MS-DRG Validation: Circulatory Disorders Except Acute Myocardial
Issue Name:
               Infarction, with Cardiac Catheterization (Medical Necessity Excluded)
Issue
               A000872010
Number
               MS-DRG Validation for MS-DRGs 286, 287. Reviewers will validate the
Issue
               principal diagnosis, secondary diagnosis and procedures that affect or can
Description:
               potentially affect the MS-DRG assignment, for the MS-DRGs listed.
Type of
               DRG Validation
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040;




               MS-DRG Validation: Amputations 239, 240, 241, 474, 475, 476 (Medical
Issue Name:
               Necessity Excluded)
Issue
               A000882010
Number
               MS-DRG Validation for MS-DRGs 239, 240, 241, 474, 475, 476. Reviewers
Issue          will validate the principal diagnosis, secondary diagnosis and procedures
Description:   that affect or can potentially affect the MS-DRG assignment, for the MS-
               DRGs listed.
Type of
               DRG Validation
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040.;




Issue Name:    MS-DRG Validation: Cervical Spinal Fusions (Medical Necessity Excluded)
Issue
               A000892010
Number
               MS-DRG Validation for MS-DRGs 471, 472, 473, 490, 491. Reviewers will
Issue          validate the principal diagnosis, secondary diagnosis and procedures that
Description:   affect or can potentially affect the MS-DRG assignment, for the MS-DRGs
               listed.
Type of
               DRG Validation
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040.;




               MS-DRG Validation: Neoplasm Surgery MS-DRGs 826, 827, 828, 829, 830,
Issue Name:
               834, 835 and 836 (Medical Necessity Excluded)
Issue
               A001092010
Number
               MS-DRG Validation for MS-DRGs 826 - 830, 834 - 836 MS-DRG validation
               requires that diagnostic and procedural information and the discharge status
Issue          of the beneficiary, as coded on the hospital claim, matches both the
Description:   attending physician description and the information contained in the medical
               record. Reviewers will validate MS-DRGs 826, 827, 828, 829, 830, 834, 835
               and 836 for diagnoses and procedures affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040.;




               MS-DRG Validation: Neoplasm MS-DRGs 837, 838, 839, 843, 844, 845,
Issue Name:
               846, 847, 848 and 849 (Medical Necessity Excluded)
Issue
               A001102010
Number
               MS-DRG Validation for MS-DRGs 837, 838, 839, 843, 844, 845, 846, 847,
               848 and 849 MS-DRG validation requires that diagnostic and procedural
               information and the discharge status of the beneficiary, as coded on the
Issue
               hospital claim, matches both the attending physician description and the
Description:
               information contained in the medical record. Reviewers will validate MS-
               DRGs 837, 838, 839, 843, 844, 845, 846, 847, 848 and 849 for diagnoses
               and procedures affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040.;




               MS-DRG Validation: (MDC 6) Hepatobiliary System and Pancreas Disorders
Issue Name:    432, 433, 434, 435, 436, 437, 439, 440, 442, 443, 445 and 446 (Medical
               Necessity Excluded)
Issue
               A001152010
Number
               MS-DRG Validation for MS-DRGs 432, 433, 434, 435, 436, 437, 439, 440,
Issue          442, 443, 445 and 446. Reviewers will validate MS-DRGs 432, 433, 434,
Description:   435, 436, 437, 439, 440, 442, 443, 445 and 446 for diagnoses and
               procedures that affect the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of       Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040.;




               MS-DRG Validation: Carotid Artery Stent Procedures (Medical Necessity
Issue Name:
               Excluded)
Issue
               A001232010
Number
               MS-DRG Validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded and reported by the
Issue          hospital on its claim, matches both the attending physician description and
Description:   the information contained in the beneficiary's medical record. Reviewers will
               validate MS-DRGs 034, 035 and 036 for principal and secondary diagnoses
               and procedures affecting or potentially affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040.;




               MS-DRG Validation: Post Operative Anemia (At this time, Medical Necessity
Issue Name:
               excluded from review)
Issue
               A000492010
Number
               MS-DRG Validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded and reported by the
Issue          hospital on its claim, matches both the attending physician description and
Description:   the information contained in the beneficiary's medical record. Reviewers will
               validate for MS-DRG 467, 481, 486, 488; principal diagnosis, secondary
               diagnoses, and procedures affecting or potentially affecting the MS-DRG.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
Issue
               incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
References
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040;




Issue Name:    Inpatient Admissions without a Physician's Inpatient Admit Order
Issue Number A001042010
Issue          Admissions to the inpatient setting require a physician's order in order to
Description:   qualify and be paid as an inpatient stay
Type of
               Complex
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted:   December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               Federal Register 11-27-2006 (42 CFR Part 482) page 2, requires
Issue          authentication of orders for the care of the patient by a physician/ provider;
References     Medicare Benefit Policy Manual – Chapter 1 Section 10; Claims Processing
               Manual Chapter 3 Section 10 and 40.2.2;




Issue Name:     Place of Service Coding for Physician Services
Issue Number A009002010
Issue           There are certain services that cannot be performed in an ASC and in a
Description:    physician office on the same date of service for the same patient.
Type of
                Automated
Review
State(s)
                CT, DC, DE MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
                Professional Services
Affected:
Date Posted:    December 7, 2010
Dates of
                Rolling 36 month review look back
Service:
                OIG Report: Review of Place of Service Coding for Physician Services #A-
Issue
                01-08-00528 OIG Report: Review of Place of Service Coding for Physician
References
                Services # A-01-08-00528 IOM 100-04 Chapter 12 Section 20.4.2;




Issue Name: Medical Necessity Review (MNR) - Renal and Urinary Tract Disorders
Issue          A001282010
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. MS-DRG: 657, 658, 660, 661, 663, 664,
               666, 667-670, 673-675, 682-685, 691-700.
Type of
               Medical Necessity Reviews
Review
State(s)
               CT, DC, DE MA, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act (Public Law 98-21); Medicare
               Program Integrity Manual (PIM) Chapter 6.5.2;; Medicare Program Integrity
               Manual (PIM) Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit
               Policy Manual Chapter 1, section 10;; Medicare Benefit Policy Manual
               Chapter 11, Section 20; Claims Processing Manual Chp 3, Section 40.2.2;
               Local Coverage Determination Highmark Medicare Services L27548;
Issue
               Medicare Inpatient Fact Sheet; Pepper Report "Top 20 DRGs for One-day
References
               Stays for Short-term Acute Care Hospitals"; OIG Report A-01-10-01000 July
               2010 "Analysis of Errors IDd in FI 2009 CERT Program"; OIG Report 09-88-
               00880 "National DRG Validation Study Unnecessary Admissions to
               Hospitals"; OIG Report A-03-00-00007 "Review of the HCFA PA Regional
               Offices Effort to ID Overpayments for 1-Day In-Pt Stays"; OIG Report oai-05-
               88-00730 "National DRG Validation Study: Short Hospitalizations";




Issue Name:    MS-DRG Validation: Urinary Procedures (Medical Necessity Excluded)
Issue
               A000662010
Number
               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
Issue          the information contained in the beneficiary's medical record. Reviewers will
Description:   validate for MS-DRGs 653, 654, 655, 656, 657, 658, 659, 660, 661, 662,
               663, 664, 665, 666, 667, 668, 669, 670, 671, 672, 673, 674, 675; principal
               diagnosis, secondary diagnoses, and procedures affecting or potentially
               affecting the MS-DRG.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: December 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG "National DRG Validation Study Special Report on Coding Accuracy",
Issue          OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
References     incorrect DRGs; PIM Chapter 6.5.3 Section A – C DRG Validation Review;
               UHDDS – Reporting of inpatient Data Elements, July 31, 1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040;




               MS-DRG Validation: Musculoskeletal Fractures 533, 534, 537, 538, 562 and
Issue Name:
               563 (Medical Necessity Excluded)
Issue
               A000912010
Number
               MS-DRG Validation for MS-DRGs 533, 534, 537, 538, 562 and 563 MS-DRG
               validation requires that diagnostic and procedural information and the
Issue          discharge status of the beneficiary, as coded on the hospital claim, matches
Description:   both the attending physician description and the information contained in the
               medical record. Reviewers will validate MS-DRGs 533, 534, 537, 538, 562
               and 563 for diagnoses and procedures affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: October 27, 2010
Dates of
               Rolling 36 month review look back
Service:
               ICD-9-CM Coding Manual (for dates of service on claim); ICD-9-CM
               Addendums & AHAs Coding Clinics; PIM, Chapter 6.5.3 - Section A-C -
Issue
               Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99) DRG
References
               Validation Review; UHDDS - Reporting of Inpatient Data Elements, July 31,
               1985; Federal Register (Vol.50, No. 147) Pages 31038-31040.;




               MS-DRG Validation: Nervous System Procedures 020, 021, 022, 023, 024,
Issue Name:    028, 029, 030, 031, 032, 033, 037, 038, 039, 040, 041 and 042 (Medical
               Necessity Excluded)
Issue
               A000942010
Number
               MS-DRG validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded on the hospital claim,
               matches both the attending physician description and the information
Issue
               contained in the medical record. Reviewers will validate the principal and
Description:
               secondary diagnoses and procedures affecting or potentially affecting
               assignment of MS DRGs 020, 021, 022, 023, 024, 028, 029, 030, 031, 032,
               033, 037, 038, 039, 040, 041 and 042.
Type of
               DRG Validation
Review
State(s)
               CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: October 7, 2010
Dates of
               Rolling 36 month review look back
Service:
Issue          OIG report “National DRG Validation Study Special Report on Coding
References     Accuracy”, OAI-12-88-01010, which indicated that 20.8% of claims were
               submitted with incorrect DRGs; 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, UHDDS - Reporting of inpatient
               Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages
               31038-31040.;




Issue Name:     Cataract Removal - Excess Units
Issue Number A000672010
                Cataract removal can only occur once per eye for the same date of service.
Issue
                This issue identifies overpayments associated to outpatient hospital
Description:
                providers billing more than on unit of cataract removal for the same eye.
Type of
                Automated
Review
State(s)
                NY, MD, PA, ME, MA, NH, VT, RI
Affected:
Providers
                Outpatient Hospitals
Affected:
Date Posted:    October 7, 2010
Dates of
                Rolling 36 month review look back
Service:
                Internet Only Manual 100-08 (Program Integrity Manual), Chapter 3,
Issue
                Subsection 3.6; NCCI Policy Manual for Medicare Services, version 15.3.
References
                Chapter 8, Section D, #3;




Issue Name: National Correct Coding Initiative (CCI) - OPPS
Issue
               A000112009
Number
               Application of the OPPS National Correct Coding Initiative (Mutually
Issue
               Exclusive and Non-Mutually Exclusive). Deny Column II code when billed by
Description:
               the same provider and same date of service as a Column I code.
Type of
               Automated
Review
State(s)
               NY, PA, CT, NJ, DC, DE
Affected:
Providers
               Outpatient Hospitals
Affected:
Date Posted: September 28, 2010
Dates of
               Rolling 36 month review look back
Service:
               Internet Only Manual 100-04 Medicare Claims Processing Manual, Chapter
               23 (Fee Schedule Administration and Coding Requirements), Subsection
               20.9 (Correct Coding Initiative), revision effective 10/1/2003; Column
Issue
               I/Column II code pairs are date sensitive. 2) Integrated Outpatient Code
References
               Editor Software, versions 8.3 (effective 10/1/2007) and higher, edit #s 19, 20,
               39, and 40.; NCCI Edits - Hospital Outpatient PPS; Outpatient Code Editor -
               Overview;
               MS-DRG Validation and Medical Necessity Review: Respiratory (At this time,
Issue Name:
               Medical Necessity Review limited to MS-DRG 190, 191, and 192)
Issue
               A001022010
Number
               Reviewers will validate the principal diagnosis, secondary diagnosis and
               procedures that affect or can potentially affect the MS-DRG assignment, for
               the MS-DRGs175, 176, 179, 180, 181, 182, 183, 184, 185, 186, 187, 188,
Issue
               190, 191, 192, 194, 195, 196, 197, 198, 199, 200, 201, 202, 203, 204, 205,
Description:
               206 and 208 for diagnoses and procedures affecting the MS-DRG
               assignment. Additionally, MS- DRGs 190, 191 and 192 will be review for
               medical necessity.
Type of
               MS-DRG Validation and Medical Necessity Review
Review
State(s)
               CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: September 9, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG report “National DRG Validation Study Special Report on Coding
               Accuracy”, OAI-12-88-01010, which indicated that 20.8% of claims were
               submitted with incorrect DRGs; 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, UHDDS – Reporting of inpatient
Issue
               Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages
References
               31038-31040; Section 1886(d) of the Social Security Act (Public Law 98-21);
               Medicare Program Integrity Manual (PIM) Chapter 6.5.2; PIM Chapter 13
               Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit Policy Manual Chapter 1,
               section 10; Medicare Benefit Policy Manual Chapter 6, Section 20.6;
               Medicare Claims Processing Manual Chapter 4, Sections 290.1 and 290.2.2;




               MS-DRG Validation and Medical Necessity Review: Gastro Intestinal
Issue Name:    Disorders. (At this time, Medical Necessity Review limited to MSDRGs 391
               and 393)
Issue
               A000962010
Number
               MS-DRG validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded on the hospital claim,
               matches both the attending physician description and the information
               contained in the medical record. Reviewers will validate MS-DRGs 332, 333,
Issue
               334, 338, 339, 340, 341, 342, 343, 344, 345, 346, 347, 348, 349, 368, 369,
Description:
               370, 374, 375, 376, 377, 378, 379, 380, 381, 382, 383, 384, 385, 386, 387,
               388, 389, 390, 391, 392, 393, 394 and 395 for diagnoses and procedures
               affecting the MS-DRG assignment. Additionally, medical records for MS
               DRGs 391 and 393 will be reviewed for medical necessity.
Type of
               MS-DRG Validation and Medical Necessity Review
Review
State(s)
               DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: September 9, 2010
Dates of
               Rolling 36 month review look back
Service:
               1) OIG report “National DRG Validation Study Special Report on Coding
               Accuracy”, OAI-12-88-01010, 2) Office of the Inspector General (OIG)
               Report A01-10-01000, 3) OIG Report OAI 09-88-00880, 4) OIG Report A-03-
               00-00007 and 5) OIG Report OAI 05-88-00730. 1) Section 1886(d) of the
               Social Security Act (Public Law 98-21); 2) CMS Internet-Only Manuals
               (IOMs), Publication 100-08; Medicare Program Integrity Manual (PIM),
               Chapter 6, Section 6.5.2 and 6.5.3; 3) Medicare Program Integrity Manual
Issue          (PIM) Chapter 13 Sections 13.1, 13.1.1 and 13.1.3; 4) Medicare Benefit
References     Policy Manual Chapter 1, Section 10; 5) Medicare Benefit Policy Manual
               Chapter 6, Section 20.6; 6) CMS IOM, Publication 100-04, Medicare Claims
               Processing Manual, Chapter 3, Section 40.2.2 (K); 7) Medicare Claims
               Processing Manual Chapter 4, Sections 290.1 and 290.2.2; 8) ICD-9-CM
               Coding Manual (for dates of service on claim); 9) ICD-9-CM Addendums and
               Coding Clinics; Uniform Hospital Discharge Data Set (UHDDS) – Reporting
               of Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No.
               147), Pages 31038-31040.;




            MS-DRG Validation and Medical Necessity Review: Diseases and Disorders
            of Blood, Blood Forming Organs and Immunological Disorders 799, 800,
Issue Name:
            801, 802, 803, 804, 808, 809, 810, 811, 812, 813, 814, 815 and 816 (MDC
            16) (At this time, Medical Necessity Review limited to MS-DRG 811)
Issue
               A001182010
Number
               MS-DRG Validation for MS-DRGs 799, 800, 801, 802, 803, 804, 808, 809,
               810, 811, 812, 813, 814, 815 and 816 (MDC 16) MS-DRG validation requires
               that diagnostic and procedural information and the discharge status of the
               beneficiary, as coded on the hospital claim, matches both the attending
Issue
               physician description and the information contained in the medical record.
Description:
               Reviewers will validate MS-DRGs 799, 800, 801, 802, 803, 804, 808, 809,
               810, 811, 812, 813, 814, 815 and 816 for diagnoses and procedures
               affecting the MS-DRG assignment. Additionally, medical records for MS
               DRG 811 will be reviewed for medical necessity.
Type of
               MS-DRG Validation and Medical Necessity Review
Review
State(s)
               DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: September 9, 2010
Dates of
               Rolling 36 month review look back
Service:
               1) OIG report “National DRG Validation Study Special Report on Coding
               Accuracy”, OAI-12-88-01010, 2) Office of the Inspector General (OIG)
               Report A01-10-01000, 3) OIG Report OAI 09-88-00880, 4) OIG Report A-03-
               00-00007 and 5) OIG Report OAI 05-88-00730. 1) Section 1886(d) of the
Issue          Social Security Act (Public Law 98-21); 2) CMS Internet-Only Manuals
References     (IOMs), Publication 100-08; Medicare Program Integrity Manual (PIM),
               Chapter 6, Section 6.5.2 and 6.5.3; 3) Medicare Program Integrity Manual
               (PIM) Chapter 13 Sections 13.1, 13.1.1 and 13.1.3; 4) Medicare Benefit
               Policy Manual Chapter 1, Section 10; 5) Medicare Benefit Policy Manual
               Chapter 6, Section 20.6; 6) CMS IOM, Publication 100-04, Medicare Claims
               Processing Manual, Chapter 3, Section 40.2.2 (K); 7) Medicare Claims
               Processing Manual Chapter 4, Sections 290.1 and 290.2.2; 8) ICD-9-CM
               Coding Manual (for dates of service on claim); 9) ICD-9-CM Addendums and
               Coding Clinics; Uniform Hospital Discharge Data Set (UHDDS) - Reporting
               of Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No.
               147), Pages 31038-31040.;




               MS-DRG Validation and Medical Necessity Review: Endocrine, Nutritional &
               Metabolic Disorders II MS-DRGs 616, 617,618, 619,620,621, 622, 623, 624,
Issue Name:
               637, 638, 639, 640, 641, 642, 643, 644 and 645 (MDC 10) (At this time,
               Medical Necessity Review limited to MS-DRG 640)
Issue
               A001162010
Number
               MS-DRG Validation for MS-DRGs 616, 617,618, 619,620,621, 622, 623,
               624, 637, 638, 639, 640, 641, 642, 643, 644 and 645 MS-DRG validation
               requires that diagnostic and procedural information and the discharge status
               of the beneficiary, as coded on the hospital claim, matches both the
Issue
               attending physician description and the information contained in the medical
Description:
               record. Reviewers will validate MS-DRGs 616, 617,618, 619,620,621, 622,
               623, 624, 637, 638, 639, 640, 641, 642, 643, 644 and 645 for diagnoses and
               procedures affecting the MS-DRG assignment. Additionally, medical records
               for MS DRG 640 will be reviewed for medical necessity.
Type of
               MS-DRG Validation and Medical Necessity Review
Review
State(s)
               DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: September 9, 2010
Dates of
               Rolling 36 month review look back
Service:
               1) OIG report “National DRG Validation Study Special Report on Coding
               Accuracy”, OAI-12-88-01010, 2) Office of the Inspector General (OIG)
               Report A01-10-01000, 3) OIG Report OAI 09-88-00880, 4) OIG Report A-03-
               00-00007 and 5) OIG Report OAI 05-88-00730. 1) Section 1886(d) of the
               Social Security Act (Public Law 98-21); 2) CMS Internet-Only Manuals
               (IOMs), Publication 100-08; Medicare Program Integrity Manual (PIM),
               Chapter 6, Section 6.5.2 and 6.5.3; 3) Medicare Program Integrity Manual
Issue          (PIM) Chapter 13 Sections 13.1, 13.1.1 and 13.1.3; 4) Medicare Benefit
References     Policy Manual Chapter 1, Section 10; 5) Medicare Benefit Policy Manual
               Chapter 6, Section 20.6; 6) CMS IOM, Publication 100-04, Medicare Claims
               Processing Manual, Chapter 3, Section 40.2.2 (K); 7) Medicare Claims
               Processing Manual Chapter 4, Sections 290.1 and 290.2.2; 8) ICD-9-CM
               Coding Manual (for dates of service on claim); 9) ICD-9-CM Addendums and
               Coding Clinics; Uniform Hospital Discharge Data Set (UHDDS) - Reporting
               of Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No.
               147), Pages 31038-31040.;




            MS-DRG Validation and Medical Necessity Review: Percutaneous
Issue Name: Cardiovascular Procedures (At this time, Medical Necessity Review limited to
            MS-DRG 249)
Issue          A000822010
Number
               MS-DRG Validation for MS-DRGs 246, 247, 249, 251. MS-DRG validation
               requires that diagnostic and procedural information and the discharge status
               of the beneficiary, as coded on the hospital claim, matches both the
Issue          attending physician description and the information contained in the medical
Description:   record. Reviewers will validate the principal diagnosis, secondary diagnosis
               and procedures that affect or can potentially affect the MS-DRG assignment,
               for the MS-DRGs listed. Additionally, medical records for MS DRG 249 will
               be reviewed for medical necessity.
Type of
               MS-DRG Validation and Medical Necessity Review
Review
State(s)
               CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: September 9, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG report “National DRG Validation Study Special Report on Coding
               Accuracy”, OAI-12-88-01010, which indicated that 20.8% of claims were
               submitted with incorrect DRGs; ICD-9-CM Coding Manual ( for dates of
Issue
               service on claim), ICD-9-CM Addendums and Coding Clinics, PIM Chapter
References
               6.5.3 Section A - C DRG Validation Review, UHDDS - Reporting of inpatient
               Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages
               31038-31040.;




               MS-DRG Validation and Medical Necessity Review: Nervous System
Issue Name:    Disorders (At this time, Medical Necessity Review limited to MS-DRGs 056
               and 057)
Issue
               A000922010
Number
               MS-DRG validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded on the hospital claim,
               matches both the attending physician description and the information
               contained in the medical record. Reviewers will validate MS-DRGs 052, 053,
Issue
               054, 055, 056, 057, 058, 059, 060, 070, 071, 072, 073, 074, 077, 078, 079,
Description:
               080, 081, 082, 083, 084, 085, 086, 087, 088, 089, 090, 091, 092, 093, 097,
               098, 099, 102 and 103 for diagnoses and procedures affecting the MS-DRG
               assignment. Additionally, medical records for MS DRGs 056 and 057 will be
               reviewed for medical necessity.
Type of
               MS-DRG Validation and Medical Necessity Review
Review
State(s)
               CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: September 9, 2010
Dates of
               Rolling 36 month review look back
Service:
               ICD-9-CM Coding Manual (for dates of service on claim); ICD-9-CM
Issue
               Addendums & AHA Coding Clinics; PIM, Chapter 6.5.3 - Section A-C -
References
               Monitoring the Accuracy of Hospital Coding (OEI-01-98-0420; 1/99) DRG
               Validation Review; UHDDS - Reporting of Inpatient Data Elements, July 31,
               1985; Federal Register (Vol.50, No.147) Pages 31038-31040; Section
               1886(d) of the Social Security Act (Public Law 98-21); Medicare Program
               Integrity Manual (PIM) Chapter 6.5.2; PIM Chapter 13 Section 13.1, 13.1.1,
               and 13.1.3; Medicare Benefit Policy Manual Chapter 1, section 10; Medicare
               Benefit Policy Manual Chapter 6, Section 20.6; Medicare Claims Processing
               Manual Chapter 4, Sections 290.1 and 290.2.2;




            MS-DRG Validation and Medical Necessity Review: Musculoskeletal
Issue Name: Disorders (At this time, Medical Necessity Review limited to MS-DRGs 551
            and 552)
Issue
               A000932010
Number
               MS-DRG Validation for MS-DRGs 539, 540, 541, 545, 546, 547, 548, 549,
               550, 551, 552, 553, 554, 555, 556, 557, 558, 564, 565 and 566 MS-DRG
               validation requires that diagnostic and procedural information and the
               discharge status of the beneficiary, as coded on the hospital claim, matches
Issue          both the attending physician description and the information contained in the
Description:   medical record. Reviewers will validate MS-DRGs 539, 540, 541, 545, 546,
               547, 548, 549, 550, 551, 552, 553, 554, 555, 556, 557, 558, 564, 565 and
               566 for diagnoses and procedures affecting the MS-DRG assignment.
               Additionally, medical records for MS DRGs 551 and 552 will be reviewed for
               medical necessity.
Type of
               MS-DRG Validation and Medical Necessity Review
Review
State(s)
               DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: September 9, 2010
Dates of
               Rolling 36 month review look back
Service:
               ICD-9-CM Coding Manual (for dates of service on claim); ICD-9-CM
               Addendums & AHAs Coding Clinics; PIM, Chapter 6.5.3 - Section A-C -
               Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99) DRG
               Validation Review; UHDDS - Reporting of Inpatient Data Elements, July 31,
Issue          1985; Federal Register (Vol.50, No. 147) Pages 31038-31040; Section
References     1886(d) of the Social Security Act (Public Law 98-21); Medicare Program
               Integrity Manual (PIM) Chapter 6.5.2; PIM Chapter 13 Section 13.1, 13.1.1,
               and 13.1.3; Medicare Benefit Policy Manual Chapter 1, section 10; Medicare
               Benefit Policy Manual Chapter 6, Section 20.6; Medicare Claims Processing
               Manual Chapter 4, Sections 290.1 and 290.2.2;




               MS-DRG Validation and Medical Necessity Review: Kidney and Urinary
               Tract Disorders 683, 684, 685, 686, 687, 688, 690, 695, 696, 697, 698, 699
Issue Name:
               and 700 (At this time, Medical Necessity Review limited to MS-DRGs 683
               and 684)
Issue
               A000972010
Number
Issue          MS-DRG validation requires that diagnostic and procedural information and
Description:   the discharge status of the beneficiary, as coded on the hospital claim,
               matches both the attending physician description and the information
               contained in the medical record. Reviewers will validate MS-DRGs 683, 684,
               685, 686, 687, 688, 690, 695, 696, 697, 698, 699 and 700 for diagnoses and
               procedures affecting the MS-DRG assignment. Additionally, medical records
               for MS DRGs 683 and 684 will be reviewed for medical necessity.
Type of
               MS-DRG Validation and Medical Necessity Review
Review
State(s)
               DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: September 9, 2010
Dates of
               Rolling 36 month review look back
Service:
               ICD-9-CM Coding Manual (for dates of service on claim); ICD-9-CM
               Addendums & AHAs Coding Clinics; PIM, Chapter 6.5.3 - Section A-C -
               Monitoring the Accuracy of Hospital Coding (OEI-01-98-00420; 1/99) DRG
               Validation Review; UHDDS - Reporting of Inpatient Data Elements, July 31,
Issue          1985; Federal Register (Vol.50, No. 147) Pages 31038-31040; Section
References     1886(d) of the Social Security Act (Public Law 98-21), 2) Medicare Program
               Integrity Manual (PIM) Chapter 6.5.2; PIM Chapter 13 Section 13.1, 13.1.1,
               and 13.1.3; Medicare Benefit Policy Manual Chapter 1, section 10; Medicare
               Benefit Policy Manual Chapter 6, Section 20.6; Medicare Claims Processing
               Manual Chapter 4, Sections 290.1 and 290.2.2;




               MS-DRG Validation and Medical Necessity Review: Diseases & Disorders of
               the Circulatory System. MS-DRGs 215, 229, 230, 232, 252-263, 265- 285,
Issue Name:
               288-290, 292-310 and 312-316 (MDC 5) (At this time, Medical Necessity
               Review limited to MS-DRG 253, 254, 292, 293, 302, 308 and 312-316)
Issue
               A001172010
Number
               MS-DRG Validation for MS-DRGs MS-DRGs 215, 229, 230, 232, 252-263,
               265- 285, 288-290, 292-310 and 312-316 MS-DRG validation requires that
               diagnostic and procedural information and the discharge status of the
               beneficiary, as coded on the hospital claim, matches both the attending
Issue
               physician description and the information contained in the medical record.
Description:
               Reviewers will validate MS-DRGs 215, 229, 230, 232, 252-263, 265- 285,
               288-290, 292-310 and 312-316 for diagnoses and procedures affecting the
               MS-DRG assignment. Additionally, medical records for MS DRGs 253, 254,
               292, 293, 302, 308 and 312-316 will be reviewed for medical necessity.
Type of
               MS-DRG Validation and Medical Necessity Review
Review
State(s)
               DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: September 9, 2010
Dates of
               Rolling 36 month review look back
Service:
               OIG “National DRG Validation Study Special Report on Coding Accuracy”
Issue
               OAI-12-88-01010, which indicated that 20.8% of claims were submitted with
References
               incorrect DRGs;; PIM Chapter 6.5.3 Section A-C DRG Validation Review;;
               UHDDS-Reporting of Inpatient Data Elements, July 31,1985, Federal
               Register (Vol.50, No. 147), Pages 31038-31040;;




               National Correct Coding Initiative (CCI) - Part B for Ambulatory Surgical
Issue Name:
               Centers
Issue
               A000102009
Number
               Application of the Part B National Correct Coding Initiative (Mutually
Issue          Exclusive and Non-Mutually Exclusive) to Ambulatory Surgical Centers.
Description:   Deny Column II code when billed by the same provider and same date of
               service as a Column I code.
Type of
               Automated
Review
State(s)
               NY, DC, DE, MD, NJ, PA, CT
Affected:
Providers
               Ambulatory Surgical Centers
Affected:
Date Posted: August 24, 2010
Dates of
               Rolling 36 month review look back
Service:
               Internet Only Manual 100-04 Medicare Claims Processing Manual, Chapter
               23 (Fee Schedule Administration and Coding Requirements), Subsection
Issue          20.9 (Correct Coding Initiative), revision effective 10/1/2003;; Internet Only
References     Manual 100-4 Medicare Claims Processing Manual, Chapter 14 (Ambulatory
               Surgical Centers), Subsection 20.9 (Rebundling of CPT codes); revision
               effective 10/1/2003. Column I/Column II code pairs are date sensitive.;




Issue Name:    MS-DRG Validation: Major Chest Procedures
Issue
               A000392009
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate for MSDRG 163, 164, 165, principal diagnosis, secondary diagnosis,
               and procedures affecting or potentially affecting the MS-DRG. At this time,
               Medical Necessity Review excluded from review.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: August 12, 2010
Dates of
               Rolling 36 month review look back
Service:
               ICD-9-CM Coding Manual ( for dates of service on claim), ICD-9-CM
Issue
               Addendums and Coding Clinics, PIM Chapter 6.5.3 Section A - C DRG
References
               Validation Review, UHDDS - Reporting of inpatient Data Elements, July 31,
               1985, Federal Register (Vol. 50, No. 147), Pages 31038-31040.;




Issue Name:    MS-DRG Validation: Extensive OR Procedure
Issue
               A000442009
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate for MS-DRG 981, 982, 983; principal diagnosis, secondary
               diagnosis, and procedures affecting or potentially affecting the MS-DRG. (At
               this time, Medical Necessity Review excluded from review)
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: August 12, 2010
Dates of
               Rolling 36 month review look back
Service:
               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
Issue
               Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, UHDDS Reporting of
References
               Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 127),
               Pages 31038-31040;




               MS-DRG Validation: Complications of Cholecystectomy (Medical Necessity
Issue Name:
               Excluded)
Issue
               A000572010
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate MS-DRGs 411, 412, 413, 414, 415, 416, 417, 418, and 419 for
               principal and secondary diagnoses and procedures affecting or potentially
               affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: August 12, 2010
Dates of
               Rolling 36 month review look back
Service:
Issue          ICD-9-CM Coding Manual (for dates of service on claim). ICD-9-CM Official
References     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;




               MS-DRG Validation: Craniotomy and Endovascular Intracranial procedures
Issue Name:
               (Medical Necessity Excluded)
Issue
               A000592010
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate MS-DRG 025, 026 and 027 for principal and secondary diagnosis
               and procedures affecting or potentially affecting the MS-DRG assignment.
               Medical Necessity excluded from review.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: August 12, 2010
Dates of
               Rolling 36 month review look back
Service:
               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
Issue
               Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, Uniform Hospital
References
               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: Joint Procedures (Medical Necessity Excluded)
Issue
               A000602010
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate MS-DRG 462, 466, 467, 468, 469 and 470 for principal and
               secondary diagnosis and procedures affecting or potentially affecting the
               MS-DRG assignment. (Medical Necessity Excluded)
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: August 12, 2010
Dates of
               Rolling 36 month review look back
Service:
               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
Issue
               Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, Uniform Hospital
References
               Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31,
               1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040;




               MS-DRG Validation: Non-extensive O.R. Procedure Unrelated to Principal
Issue Name:
               Diagnosis (Medical Necessity Excluded)
Issue
               A000632010
Number
               MS-DRG Validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded and reported by the
Issue          hospital on its claim, matches both the attending physician description and
Description:   the information contained in the beneficiary's medical record. Reviewers will
               validate MS-DRG 987, 988 and 989 for principal and secondary diagnosis
               and procedures affecting or potentially affecting the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: August 12, 2010
Dates of
               Rolling 36 month review look back
Service:
               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
Issue
               Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, Uniform Hospital
References
               Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31,
               1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040;




               MS-DRG Validation: Hip and Femur Procedures (Medical Necessity
Issue Name:
               Excluded)
Issue
               A000712010
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate MS-DRGs 495, 496, 497, 498 and 499 for principal and secondary
               diagnosis and procedures affecting or potentially affecting the MS-DRG
               assignment. At this time, Medical Necessity Review excluded from review.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: August 12, 2010
Dates of
               Rolling 36 month review look back
Service:
               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
Issue
               Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, Uniform Hospital
References
               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: Pathological Fractures (Medical Necessity Excluded)
Issue
               A000732010
Number
               MS-DRG Validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded and reported by the
Issue          hospital on its claim, matches both the attending physician description and
Description:   the information contained in the beneficiary's medical record. Reviewers will
               validate MS-DRGs 542, 543, 544 for principal and secondary diagnosis and
               procedures that affect or can potentially affect the MS-DRG assignment.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: August 12, 2010
Dates of
               Rolling 36 month review look back
Service:
               Addendums and Coding Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review,
Issue          Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
References     Elements, July 31, 1985, Federal Register (Vol. 50, No. 127), Pages 31038-
               31040;




Issue Name:    MS-DRG Validation: Seizures (Medical Necessity Excluded)
Issue
               A000742010
Number
               MS-DRG Validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded and reported by the
Issue          hospital on its claim, matches both the attending physician description and
Description:   the information contained in the beneficiary's medical record. Reviewers will
               validate for MS-DRGs 100, 101; principal diagnosis, secondary diagnosis
               and procedures that affect or can potentially affect the MS-DRG.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: August 12, 2010
Dates of
               Rolling 36 month review look back
Service:
               Addendums and Coding Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review,
Issue          Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
References     Elements, July 31, 1985, Federal Register (Vol. 50, No. 127), Pages 31038-
               31040;




Issue Name:     Date of Death-DME
Issue Number A009012010
Issue           Medicare does not typically pay for services or equipment provided after
Description:    the beneficiary's date of death.
Type of
                Automated
Review
State(s)
                CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
                DME Suppliers
Affected:
Date Posted:    August 11, 2010
Dates of
                Rolling 36 month review look back
Service:
                IOM Publication 100-01 Chapter 2 Section 40.5; IOM Publication 100-4
Issue
                Chapter 20 Section 30.5.4; IOM Publication 100-02, Chapter 15 , Section
References
                110.1; OIG Report March 2000 – OEI-03-99-00200;




Issue Name:      Date of Death-Inpatient
Issue Number     A009022010
Issue            Medicare does not typically pay for services or equipment rendered after
Description:     the beneficiary's date of death.
Type of Review Complex
State(s)
                 CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
                 Inpatient Hospitals
Affected:
Date Posted:     August 11, 2010
Dates of
                 Rolling 36 month review look back
Service:
Issue            IOM Publication 100-01 Chapter 2 Section 40.5; IOM Publication 100-04
References       Chapter 3 Section 40.2.2; OIG Report March 2000 – OEI-03-99-00200;




Issue Name:    Technical Component of Radiology
Issue
               A000232009
Number
               A potential vulnerability may exist when the technical component (TC) of
               radiology services are furnished to patients in a Prospective Payment
Issue
               System (PPS) hospital setting and are billed separately to Part B. Therefore,
Description:
               an issue may exist when these codes are billed and are reimbursed under
               Medicare Part B in this manner.
Type of
               Automated
Review
State(s)
               CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Physician (Carrier) / Outpatient Hospital
Affected:
Date Posted: June 17, 2010
Dates of
               Rolling 36 month review look back
Service:
Issue
               IOM 100-04. Chapter 13. Section 20.2.1, OIG Report A-01-04-00528;
References




               MS-DRG Validation and Medical Necessity Review: Severe Sepsis (At this
Issue Name:
               time, Medical Necessity Review limited to MS-DRGs 291, 682, and 689)
Issue
               A000382009
Number
               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
Issue          the information contained in the beneficiary's medical record. Reviewers will
Description:   validate for MS DRGs 177, 189, 193, 291, 438, 441, 444, 592, 602, 682,
               689, 691, 693; principal diagnosis, secondary diagnosis, and procedures
               affecting or potentially affecting the MS-DRG. Additionally, medical records
               for MS DRGs 291, 682, and 689 will be reviewed for medical necessity.
Type of
               MS-DRG Validation and Medical Necessity Review
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: June 17, 2010
Dates of
               Rolling 36 month review look back
Service:
               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)
Issue          Demonstration Table P3 and Table P4, Page 57. OIG Report OEI-03-98-
References     00370, March 1999; Section 1886(d) of the Social Security Act (Public Law
               98-21); Medicare Program Integrity Manual (PIM) Chapter 6.5.2; PIM
               Chapter 13 Section 13.1, 13.1.1, and 13.1.3; Medicare Benefit Policy Manual
               Chapter 1, section 10; Medicare Benefit Policy Manual Chapter 6, Section
               20.6; Medicare Claims Processing Manual Chapter 4, Sections 290.1 and
               290.2.2;




               MS-DRG Validation: Cardiac Valve Procedures (Medical Necessity
Issue Name:
               Excluded)
Issue
               A000562010
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate for MS-DRG 216, 217, 218, 219, 220, 221; principal diagnosis,
               secondary diagnoses, and procedures affecting or potentially affecting the
               MS-DRG.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: June 17, 2010
Dates of
               Rolling 36 month review look back
Service:
               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
Issue
               Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, Uniform Hospital
References
               Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31,
               1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040;




               MS-DRG Validation: Coronary Bypass Procedures (Medical Necessity
Issue Name:
               Excluded)
Issue
               A000582010
Number
               MS-DRG Validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded and reported by the
Issue          hospital on its claim, matches both the attending physician description and
Description:   the information contained in the beneficiary's medical record. Reviewers will
               validate for MS-DRG 234, 236; principal diagnosis, secondary diagnoses,
               and procedures affecting or potentially affecting the MS-DRG.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: June 17, 2010
Dates of
               Rolling 36 month review look back
Service:
               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
Issue
               Clinics. PIM 6.5.3 A-C DRG Validation Review, Uniform Hospital Discharge
References
               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: Lysis of Adhesions (Medical Necessity Excluded)
Issue          A000612010
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate for MS-DRGs 335, 336, 337, 350, 351, 352, 353, 354, 355 principal
               diagnosis, secondary diagnosis and procedures that affect or can potentially
               affect the MS-DRG assignment, for the MS-DRGs listed.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: June 17, 2010
Dates of
               Rolling 36 month review look back
Service:
               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
Issue
               Clinics. PIM 6.5.3 A-C DRG Validation Review, Uniform Hospital Discharge
References
               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: Excisional Debridement
Issue
               A000452009
Number
               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
Issue          the information contained in the beneficiary's medical record. Reviewers will
Description:   validate for MS-DRG 463, 464, 465, 573, 574, 575, 901, 902, 903; principal
               diagnosis, secondary diagnosis, and procedures affecting or potentially
               affecting the MS-DRG. (At this time, Medical Necessity Review excluded
               from review)
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, CT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: June 17, 2010
Dates of
               Rolling 36 month review look back
Service:
               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
Issue
               Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 127),
References
               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:    Global vs. TC/PC Split Reimbursements
Issue
               A000212009
Number
               A potential vulnerability may exist when providers are reimbursed for global
               procedures and then receive additional reimbursement for technical (modifier
Issue
               TC) and/or professional (modifier 26) components for the same service.
Description:
               Therefore, an issue may exist when these codes are billed and are
               reimbursed under Medicare Part B in this manner.
Type of
               Automated
Review
State(s)
               CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Physician (Carrier) / Outpatient Hospital
Affected:
Date Posted: June 17, 2010
Dates of
               Rolling 36 month review look back
Service:
               IOM 100-04, Chapter 1, Section 120; IOM 100-04, Chapter 12, Section 20.2;
Issue
               IOM 100-04, Chapter 13, Section 20.1-20.2.3; IOM 100-04, Chapter 16,
References
               pages 80.2.1;




Issue Name:    IV Hydration
Issue Number A000182009
               A potential vulnerability may exist if certain IV Hydration Codes are billed for
Issue          more than one unit per date of service. Therefore, an issue may exist when
Description:   these codes are billed and are reimbursed under Medicare Part B in this
               manner.
Type of
               Automated
Review
State(s)
               CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Physician (Carrier) / Outpatient Hospital
Affected:
Date Posted:   June 17, 2010
Dates of
               Rolling 36 month review look back
Service:
Issue          IOM 100-04, Chapter 12, pages 31-32; IOM 100-20, Transmittal 419, page
References     7;




Issue Name:    Bronchoscopy Services
Issue Number A000172009
               A potential vulnerability may exist if certain bronchoscopy services are billed
Issue          for more than one unit per date of service. Therefore, an issue may exist
Description:   when these codes are billed and are reimbursed under Medicare Part B in
               this manner.
Type of
               Automated
Review
State(s)
               CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Physician (Carrier) / Outpatient Hospital
Affected:
Date Posted:   June 17, 2010
Dates of
               Rolling 36 month review look back
Service:
Issue
               Federal Register, Volume 67, No. 251, page 8;
References




Issue Name:    Blood Transfusions
Issue Number A000162009
               A potential vulnerability may exist if certain blood transfusion codes are
Issue          billed for more than one unit per date of service. Therefore, an issue may
Description:   exist when these codes are billed and are reimbursed under Medicare Part
               B in this manner.
Type of
               Automated
Review
State(s)
               CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Physician (Carrier) / Outpatient Hospital
Affected:
Date Posted:   June 17, 2010
Dates of
               Rolling 36 month review look back
Service:
Issue
               IOM 100-04, Chapter 4, Section 231.8;
References




Issue Name:    Untimed Codes
Issue Number A000152009
               A potential vulnerability may exist if certain codes are billed for more than
Issue
               one unit. Therefore, an issue may exist when these codes are billed and
Description:
               are reimbursed under Medicare Part B in this manner.
Type of
               Automated
Review
State(s)
               CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Physician (Carrier) / Outpatient Hospital
Affected:
Date Posted:   June 17, 2010
Dates of
               Rolling 36 month review look back
Service:
Issue          IOM 100-04, Chapter 5, Section 20.2; IOM 100-04, Transmittal 1019, dated
References     8.3.06, pages 7-11;
Issue Name:    Neulasta
Issue Number A000142009
               A potential vulnerability may exist if the code J2505 is billed with more than
Issue          1 unit per patient per date of service. Therefore, an issue may exist when
Description:   these codes are billed and are reimbursed under Medicare Part B inside of
               this time frame.
Type of
               Automated
Review
State(s)
               CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Physician (Carrier) / Outpatient Hospital
Affected:
Date Posted:   June 17, 2010
Dates of
               Rolling 36 month review look back
Service:
Issue          IOM 100-04, Transmittal 949 (dated May 12, 2006), HCPCS Level II 2007,
References     2008, 2009;




Issue Name:     Once In A Lifetime
Issue Number    A000132009
                Certain codes may only be billed once in a lifetime. Therefore, an issue
Issue
                may exist when these codes are billed and are reimbursed under Medicare
Description:
                Part B inside of this time frame.
Type of
                Automated
Review
State(s)
                CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
                Physician (Carrier) / Outpatient Hospital
Affected:
Date Posted:    June 17, 2010
Dates of
                Rolling 36 month review look back
Service:
Issue
                References IOM 100-08, Chapter 3 Section 3.6.;
References




Issue Name:    Newborn/Pediatric Codes
Issue Number A000122009
               Providers should not bill new Newborn/Pediatric Codes for patients which
Issue          exceed the age limit defined by the CPT Code. Therefore, an issue may
Description:   exist when Newborn/Pediatric Codes and are reimbursed under Medicare
               Part B outside of the age limit.
Type of
               Automated
Review
State(s)
               CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Physician (Carrier) / Outpatient Hospital
Affected:
Date Posted:   June 17, 2010
Dates of
               Rolling 36 month review look back
Service:
Issue          American Medical Association (AMA), Current Procedural Terminology
References     2007, 2008, 2009;




Issue Name:      New Patient Visits
Issue Number A000072009
                 dentification of overpayments relating to the same provider group and
Issue
                 specialty billing more than on new patient Evaluation and Management
Description:
                 services within a 3 year period of time.
Type of
                 Automated
Review
State(s)
                 NY, CT, DC, DE, MD, NJ, PA
Affected:
Providers
                 Physician (Carrier) / Outpatient Hospital
Affected:
Date Posted:     June 17, 2010
Dates of
                 Rolling 36 month review look back
Service:
Issue
                 IOM 100-04 Chapter 12, Section 30.6.7;
References




Issue Name:          Duplicate Claims - Part B
Issue Number         A000462009
Issue Description: Identification of overpayment made on duplicate claims.
Type of Review       Automated
State(s) Affected:   NY, NJ, DC, PA, MD, DE, CT
Providers
                     Professional Services
Affected:
Date Posted:         June 17, 2010
Dates of Service:    Rolling 36 month review look back
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
               Overpayment associated to providers billing for global services in a facility
Issue          setting as the technical component should be billed by the facility where the
Description:   procedure was done. Diagnostic tests and radiology services submitted
               globally in facility place of service will be repriced with modfiier 26.
Type of
               Automated
Review
State(s)       NY
Affected:
Providers
               Professional Services
Affected:
Date Posted:   June 17, 2010
Dates of
               Rolling 36 month review look back
Service:
Issue
               IOM 100-04 Chapter 13, Section 20.2.1; IOM 100-04 Chapter 23;
References




Issue Name: Global Surgery - Pre and Post-Operative Visits
Issue
               A000032009
Number
               Identification of overpayments associated to minor and major surgical
               services. 1) E/M services (as specifically defined in the IOM) billed the day
               prior to a major (90-day) surgical service without modifiers 57 or 25. 2) E/M
Issue          services (as specifically defined in the IOM) billed the day of a major (90-
Description:   day) or minor (0- or 10-day) surgical service billed without modifier 25 or 57.
               3) E/M services (as specifically defined in the IOM) billed 10 days following a
               10-day minor surgical service or 90 days following a 90-day major surgical
               service and billed without modifier 24 (unrelated visit in post op period).
Type of
               Automated
Review
State(s)
               NY, NJ, PA, CT, DC, DE, MD
Affected:
Providers
               Professional Services
Affected:
Date Posted: June 17, 2010
Dates of
               Rolling 36 month review look back
Service:
Issue
               IOM 100-04 Chapter 12, Section 40.1, 40.3;
References




Issue Name:     National Correct Coding Initiative (CCI) - Part B
Issue Number A000022009
                Application of the Part B National Correct Coding Initiative (Mutually
Issue
                Exclusive and Non-Mutually Exclusive). Deny Column II code when billed
Description:
                by the same provider and same date of service as a Column I code.
Type of
                Automated
Review
State(s)
                PA, DE, DC, MD, CT, NJ, NY
Affected:
Providers
                Professional Services
Affected:
Date Posted:    June 17, 2010
Dates of
                Rolling 36 month review look back
Service:
Issue           IOM 100-04 Chapter 12, Section 30; IOM 100-04 Chapter 23, Section 20.9;
References




Issue Name:     Add-On Codes Paid without a Paid Required Primary Procedure
Issue Number    A000012009
                Claims overpaid for add-on codes when the required primary procedure is
Issue
                not billed by the same provider on any claim (same or different) for the
Description:
                same date of service.
Type of
                Automated
Review
State(s)
                NY, NJ, PA, DE, DC, MD, CT
Affected:
Providers
                Professional Services
Affected:
Date Posted:    June 17, 2010
Dates of
                Rolling 36 month review look back
Service:
Issue
                IOM 100-04 Chapter 12, Section 30;
References




Issue Name:    Parenteral Nutrition Additives with Premix Solutions
Issue
               A000522010
Number
               When premix parenteral nutrition solutions are used (B4189, B4193, B4197,
               B4199, B5000, B5100, B5200) there must be no separate billing for the
Issue
               carbohydrates (B4164, B4180), amino acids (B4168, B4178) or additives
Description:
               (B4216: vitamins, trace elements, heparin, electrolytes). However, lipids
               (B4185) are separately billable with premix solutions.
Type of
               Automated
Review
State(s)
               CT, PA
Affected:
Providers
               DME Suppliers
Affected:
Date Posted: June 17, 2010
Dates of
               Rolling 36 month review look back
Service:
Issue
               Article A37215; LCD L5063;
References




Issue Name:     Manual Wheelchair Accessories Billed With Power Wheelchair Bases
Issue Number    A000702010
                Overpayments associated to payment of manual wheelchair accessories
Issue
                billed with power wheelchair base on the same date of service for the
Description:
                same beneficiary.
Type of         Automated
Review
State(s)
                CT, MA, NJ, PA, NY, MD
Affected:
Providers
                DME Suppliers
Affected:
Date Posted:    June 10, 2010
Dates of
                Rolling 36 month review look back
Service:
Issue
                LCD L11473;
References




Issue Name: Initial/Preparatory Knee Disarticulation Prosthesis
Issue
               A000692010
Number
               When an above knee initial prosthesis (L5505) or an above knee preparatory
               (L5560-L5580, L5590-L5600) prosthesis is provided, prosthetic substitution
Issue          and/or additions of procedures and components are covered in accordance
Description:   with the functional level assessment except for codes L5610, L5631, L5640,
               L5642, L5644, L5648, L5705, L5706, L5964, L5980, and L5710-L5780,
               L5790-L5795 which will be denied as not medically necessary.
Type of
               Automated
Review
State(s)
               PA, NY, CT, MA
Affected:
Providers
               DME Suppliers
Affected:
Date Posted: June 10, 2010
Dates of
               Rolling 36 month review look back
Service:
Issue
               LCD L11464;
References




               MS-DRG Validation: Liver Transplant (At this time, Medical Necessity
Issue Name:
               excluded from review)
Issue
               A000502010
Number
               MS-DRG Validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded and reported by the
Issue          hospital on its claim, matches both the attending physician description and
Description:   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
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: May 11, 2010
Dates of
               Rolling 36 month review look back
Service:
               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
Issue
               Validation Review, Uniform Hospital Discharge Data Set (UHDDS) -
References
               Reporting of inpatient Data Elements, July 31, 1985, Federal Register (Vol.
               50, No. 147), Pages 31038- 31040.;




               MS-DRG Validation: Heart Transplant (At this time, Medical Necessity
Issue Name:
               excluded from review)
Issue
               A000512010
Number
               MS-DRG Validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded and reported by the
Issue          hospital on its claim, matches both the attending physician description and
Description:   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
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: May 11, 2010
Dates of
               Rolling 36 month review look back
Service:
               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
Issue
               Validation Review, Uniform Hospital Discharge Data Set (UHDDS) -
References
               Reporting of inpatient Data Elements, July 31, 1985, Federal Register (Vol.
               50, No. 147), Pages 31038- 31040.;




Issue Name: MS-DRG Validation: Human Immunodeficiency Virus (HIV) Disease
Issue
               A000422009
Number
             MS-DRG Validation requires a 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. Per ICD-9 CM Official Guidelines for
Issue        Coding and Reporting section 1.C.1.A.2.A if a patient is admitted for an HIV
Description: related condition the principal diagnosis should be 042, followed by
             additional diagnosis codes for all reported HIV related conditions. In addition,
             section 1.C.1.A. 2.F. states patients with any known prior diagnosis of an HIV
             related illness should be coded to 042. Once a patient has developed an HIV
             related illness the patient should always be assigned the code 042 on every
             subsequent admission/encounter. Principal diagnosis, secondary diagnoses,
             and procedures affecting or potentially affecting the claim will be reviewed for
               accuracy. At this time, medical necessity is excluded from review.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: May 11, 2010
Dates of
               Rolling 36 month review look back
Service:
               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
Issue
               Clinics; PIM Ch 6.5.3 A-C DRG Validation Review; UHDDS - Reporting of
References
               Inpatient Data Elements, July 31, 1985; Federal Register (Vol. 50, No. 127),
               Pages 31038- 31040;




Issue Name: IPPS Hospital to Hospital Transfers
Issue
               A000082009
Number
               Medicare pays full medical severity diagnosis-related group (MS-DRG)
               payments to the final discharging hospital. Payment to the transferring
               hospital is based upon a per diem rate. Hospitals, who admit, stabilize, and
Issue
               transfer patients to other hospitals generally use fewer resources than
Description:
               hospitals providing the full scope of medical treatment. An improperly
               reported transfer normally results in an overpayment when both hospitals
               receive full MS-DRG payments.
Type of
               Automated
Review
State(s)
               CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 31, 2010
Dates of
               Rolling 36 month review look back
Service:
               Section 1886(d) of the Social Security Act; Internet-Only Manual (IOM),
Issue
               Publication100-04, Chapter 3, Sections 20.1.2.4 and 40.2.4,; Code of
References
               Federal Regulations 42 CFR 412.4;




               MS-DRG Validation: Cardiac Procedures (used to be called Myocardial
Issue Name:
               Infarction)
Issue
               A000412009
Number
               MS-DRG Validation requires that diagnostic and procedural information and
               the discharge status of the beneficiary, as coded and reported by the
Issue          hospital on its claim, matches both the attending physician description and
Description:   the information contained in the beneficiary's medical record. Reviewers will
               validate for MS-DRGs 228, 231, 233, 235, 237, 248, 250; principal diagnosis,
               secondary diagnosis, and procedures affecting or potentially affecting the
               MS-DRG.(At this time, Medical Necessity Review excluded from review)
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 23, 2010
Dates of
               Rolling 36 month review look back
Service:
               ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM
Issue
               Addendums and Coding Clinics, PIM Ch 6.5.3, Section A-C, DRG Validation
References
               Review, DRG Desk Reference Ingenix 2009. CodeWrite, April 2007; AHIMA;




Issue Name: MS-DRG Validation: Major Small and Large Bowel Procedures
Issue
               A000402009
Number
               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
Issue
               the information contained in the beneficiary's medical record. Reviewers will
Description:
               validate for MS-DRG 329, 330, and 331, principal diagnosis, secondary
               diagnosis, and procedures affecting or potentially affecting the MS-DRG. At
               this time, Medical Necessity Review excluded from review.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 23, 2010
Dates of
               Rolling 36 month review look back
Service:
               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
Issue          Validation Review, UHDDS - Reporting of inpatient Data Elements, July 31,
References     1985, Federal Register (Vol. 50, No. 147), Pages 31038-31040.
               CERT/HPMP Report, November 2006, Table 13d, RAC Demonstration Table
               H1 page 45.;




               MS-DRG Validation and Medical Necessity Review: Acute Ischemic Stroke
               w/use of Thrombolytic Agent: Intracranial Hemorrhage or Cerebral Infarction:
Issue Name:
               Nonspecific CVA & Precerebral Occlusion: Transient Ischemia (At this time,
               Medical Necessity Review limited to MS-DRG 069)
Issue
               A000432009
Number
               MS-DRG Validation requires that diagnostic and procedural information and
Issue
               the discharge status of the beneficiary, as coded and reported by the
Description:
               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 061, 062, 063, 064, 065, 066, 067, 068, 069 principal
               diagnosis, secondary diagnosis, and procedures affecting or potentially
               affecting the MS-DRG. Additionally, medical records for MS DRG 069 will be
               reviewed for medical necessity.
Type of
               MS-DRG Validation and Medical Necessity Review
Review
State(s)
               NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: March 23, 2010
Dates of
               Rolling 36 month review look back
Service:
               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
Issue
               Validation Review, UHDDS - Reporting of inpatient Data Elements, July 31,
References
               1985, Federal Register (Vol. 50, No. 147), Pages 31038-31040. OIG Report
               Validation of DRG 14 (MS-DRG 064, 065, 066), January 1988.;




Issue Name:     Oxygen Accessories
Issue Number A000332009
                Overpayment for oxygen accessories made when an oxygen system rental
Issue
                has occurred in the month prior to the date of service associated to the
Description:
                accessory billing or in the subsequent month.
Type of
                Automated
Review
State(s)
                NJ, PA
Affected:
Providers
                DME Suppliers
Affected:
Date Posted:    February 10, 2010
Dates of
                Rolling 36 month review look back
Service:
Issue
                LCD L11468; LCD Policy Article A33768;
References




               MS-DRG Validation: MS-DRG 189 Pulmonary Edema & Respiratory Failure
Issue Name:
               (At this time, Medical Necessity is excluded from review)
Issue
               A000352009
Number
               DRG Validation requires that diagnostic and procedural information and the
               discharge status of the beneficiary, as coded and reported by the hospital on
Issue          its claim, matches both the attending physician description and the
Description:   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        DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT. PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: January 19, 2010
Dates of
               Rolling 36 month review look back
Service:
               ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM
Issue          Addendums and Coding Clinics, PIM Ch 6.5.3, Section A - C - DRG
References     Validation Review, OIG Report DRG 87: Pulmonary Edema and Respiratory
               Failure, August 1989;




               DRG Validation: Tracheostomy (At this time, Medical Necessity excluded
Issue Name:
               from review)
Issue
               A000362009
Number
               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
Issue
               information contained in the beneficiary's medical record. Reviewers will
Description:
               validate for MS DRGs 003, 004, 011, 012, 013; principal diagnosis,
               secondary diagnosis, and procedures affecting or potentially affecting the
               DRG. At this time, Medical Necessity Review is excluded from review.
Type of
               DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT. PA, DE, DC, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: January 19, 2010
Dates of
               Rolling 36 month review look back
Service:
               ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM
Issue          Addendums and Coding Clinics, PIM Ch 6.5.3 A-C DRG Validation Review;
References     UHDDS - Reporting of Inpatient Data Elements, July 31, 1985, Federal
               Register (Vol. 50, No. 147), Pages 31038-31040;




               MS-DRG Validation for MS-DRGs with Ventilator Support of 96+ Hours (At
Issue Name:
               this time, Medical Necessity is excluded from review)
Issue
               A000302009
Number
               The descriptions of MS-DRGs 003, 004, 207, 870, 927 and 933 all clearly
               state with ventilator support of 96+ hours. This requires a minimum hospital
Issue          stay of 96 hours. Claims with admissions of less than 96+ hours have been
Description:   identified with these DRGs reported, along with claims with length of stay of
               5 days or less. It is unlikely for a patient to be on a ventilator for 96 hours
               with a 5 day length of stay or less.
Type of        DRG Validation
Review
State(s)
               NY, NH, MA, ME, VT. PA, DE, DC, MD, RI, CT, NJ
Affected:
Providers
               Inpatient Hospitals
Affected:
Date Posted: January 19, 2010
Dates of
               Rolling 36 month review look back
Service:
               ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM
Issue          Addendums and Coding Clinics, PIM Ch 6.5.3, Section A - C - DRG
References     Validation Review, DRG Desk Reference Ingenix 2009. CodeWrite, April
               2007; AHIMA;




Issue Name:    Ambulance Unbundled Services During an Inpatient Hospital Stay
Issue
               A000062009
Number
Issue          Ambulance Supplier of unbundled services should bill the hospital for
Description:   services for inpatients, and not bill separately under Part B.
Type of
               Automated
Review
State(s)
               DE, DC, NJ, PA, CT, NY, ME, MA, NH, RI, VT
Affected:
Providers
               Ambulance Providers
Affected:
Date Posted: January 7, 2010
Dates of
               Rolling 36 month review look back
Service:
               Internet Only Manual, Medicare Benefit Policy Manual Publication 100-02
               Chapter 10, Section 10 and 10.3.3; Internet Only Manual, Medicare
Issue          Processing Manual, Publication 100-04, Chapter 3, Sections 10.4 and 10.5.;
References     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.;




Issue Name:    Solid Insert with Seat or Back Wheelchair Cushions
Issue Number A000262009
               Code E0992 (solid seat insert) is not separately payable when provided with
Issue          a seat or a seat back wheelchair cushion. Therefore an issue may exist
Description:   when E0992 is billed and reimbursed under Medicare Part B with a seat or
               seat back wheelchair cushion.
Type of
               Automated
Review
State(s)
               VT, NH, ME, MA, RI, CT, NY, NJ, PA, MD, DE, DC
Affected:
Providers
               DME Suppliers
Affected:
Date Posted:   December 22, 2009
Dates of
               Rolling 36 month review look back
Service:
Issue
               LCD Policy Article A17918;
References




Issue Name:    Lower Limb Suction Valve Prosthesis
Issue
               A000252009
Number
               L5647 (Addition to lower extremity, below knee, suction socket), L5652
               (Addition to lower extremity, suction suspension, above knee or knee
Issue
               disarticulation socket), L5671 (Addition to lower extremity, below knee/above
Description:
               knee suspension locking mechanism [shuttle, lanyard, or equal], excludes
               suction socket).
Type of
               Automated
Review
State(s)
               CT, DC, DE, MA, MD, NH, NJ, NY, PA, RI
Affected:
Providers
               DME Suppliers
Affected:
Date Posted: December 22, 2009
Dates of
               Rolling 36 month review look back
Service:
               Local Coverage Article A25310, associated to Local Coverage
Issue          Determination L11464 (Lower Limb Prosthesis), effective 1/1/2007; Region
References     A DMERC PSC Bulletin Bul20030901, "Use of HCPCS Code L5647 and
               L5652-Clarification", September 2003;




Issue Name:    Prosthetic Additions with Initial or Preparatory Knee Prosthesis
Issue
               A000282009
Number
               Overpayments associated to certain prosthetic subsitutions and/or additional
               or procedures and components (L5629, L5638, L5639, L5646, L5647,
Issue
               L5704, L5785, L5962, L5980) billed by the same provider on the same date
Description:
               of service as an initial below knee prosthesis (L5500) or a preparatory below
               knee prosthesis (L5510-L5530, L5540).
Type of
               Automated
Review
State(s)
               NJ, PA, MD, MA, ME, CT, DC, DE, NY
Affected:
Providers
               DME Suppliers
Affected:
Date Posted: December 22, 2009
Dates of
               Rolling 36 month review look back
Service:
Issue
               LCD Policy L11464;
References
Issue Name:       Multiple DME Rentals within a Month
Issue Number      A000042009
Issue             Overpayments associated to DMEPOS suppliers billing multiple rentals
Description:      for the same equipment within the same month.
Type of Review    Automated
State(s)
                  CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
                  DME Suppliers
Affected:
Date Posted:      December 22, 2009
Dates of
                  Rolling 36 month review look back
Service:
Issue             CMS Pub.100-4, Ch 20, § 30.1, 30.2, 30.5, 30.7, 13.8; Social Security
References        Act, Volume I, Title XVIII, Section 1834;




                 Headrest with a Power Operated Vehicle or a Power Wheelchair with a
Issue Name:
                 Captain's Chair Seat
Issue Number A000272009
                 Overpayments associated to payment of headrests (E0955) billed the same
Issue
                 date of service as a Power Operated Vehicle (POV) or Power Wheelchair
Description:
                 (PWC) with a captain's chair seat.
Type of
                 Automated
Review
State(s)
                 NJ, PA, DE, MA, MD, ME, NH, NY
Affected:
Providers
                 DME Suppliers
Affected:
Date Posted:     December 22, 2009
Dates of
                 Rolling 36 month review look back
Service:
Issue
                 LCD Policy L15845;
References




Issue Name:      Wheel Attachment with New Non-Wheeled Walker
Issue Number     A000292009
                 An overpayment exists when wheel attachment (E0155) is paid the same
Issue
                 day or within one month of the initial issue of a nonwheeled walker (E0130,
Description:
                 E0135, E0140, E0148).
Type of
                 Automated
Review
State(s)
                 VT, NH, ME, MA, RI, CT, NY, NJ, PA, MD, DE, DC
Affected:
Providers
                 DME Suppliers
Affected:
Date Posted:     December 22, 2009
Dates of         Rolling 36 month review look back
Service:
Issue           DME MAC Region A Local Coverage Article A35351 (Walkers), associated
References      to Local Coverage Determination L11472 (Walkers), effective 5/5/2005;




Issue Name:    Clinical Social Worker during Inpatient Hospital
Issue
               A000222009
Number
               CSW services rendered during an inpatient acute care or skilled nursing
               facility stay are not separately payable under Medicare Part B, instead they
               are included in the facility’s Prospective Payment System (PPS) payment.
Issue
               CSW providers are expected to render services under arrangement with the
Description:
               facility. Therefore, an issue may exist when a beneficiary received CSW
               services during an inpatient stay, which have been billed and reimbursed
               under Medicare Part B.
Type of
               Automated
Review
State(s)
               CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
               CSW Providers
Affected:
Date Posted: December 11, 2009
Dates of
               Rolling 36 month review look back
Service:
Issue          Medicare Benefit Policy Manual: Pub100-2, Ch15, § 170; CMS MedLearn
References     Matters Article #: SE0439.;




Issue Name: Pharmacy Supply and Dispensing Fees
Issue
               A000052009
Number
               Pharmacy supply and dispensing fees are required to be accompanied with
Issue          an oral anti-cancer, oral antiemetic, immunosuppressive drug or inhalation
Description:   drug. The absence of one of the aforementioned drugs billed on the claim or
               a denial of one of the aforementioned drugs represents an overpayment.
Type of
               Automated
Review
State(s)
               NY, NJ, CT, MA, ME, NH, VT
Affected:
Providers
               DME Suppliers
Affected:
Date Posted: September 18, 2009
Dates of
               Rolling 36 month review look back
Service:
               Internet Only Manual 100-04 (Medicare Claims Processing Manual), Chapter
               17 (Drugs and Biologicals), Section 80.7; Transmittal 754, Change Request
Issue          3990, Requirement 3990.15.; DME MAC Jurisdiction A Article for Nebulizers
References     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);




Issue Name:      Wheelchair Bundling
Issue Number     A000202009
                 A potential issue may exist if certain procedure codes are billed in
Issue
                 conjunction with other procedure codes for the same date of service and
Description:
                 the same beneficiary.
Type of
                 Automated
Review
State(s)
                 CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
                 DME Suppliers
Affected:
Date Posted:     September 18, 2009
Dates of
                 Rolling 36 month review look back
Service:
Issue
                 LCD L11473, CMS Pub.100-3, Ch1, § 280.1 & 280.3;
References




Issue Name:     Urological Bundling
Issue Number    A000192009
                A potential issue may exist if certain urological procedure codes are billed
Issue
                in conjunction with other urological procedure codes for the same date of
Description:
                service and same beneficiary.
Type of
                Automated
Review
State(s)
                CT, DC DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
                DME Suppliers
Affected:
Date Posted:    September 18, 2009
Dates of
                Rolling 36 month review look back
Service:
Issue
                CMS Pub.100-3, Ch1, § 230.17; LCD L5080; LCD Policy Article 25230;
References




               Medical Necessity Review (MNR) for MS-DRG 182 Respiratory Neoplasms
Issue Name:
               without CC/MCC
Issue
               A000872011
Number
               Medicare pays for inpatient hospital services that are medically necessary for
Issue          the setting billed. Medical documentation will be reviewed to determine that
Description:   services were medically necessary. This review will be of MS-DRG 182
               Respiratory Neoplasms without CC/MCC
Type of        Medical Necessity Review
Review
State(s)
              NY, NH, MA, ME, VT, PA, DE, DC, RI, CT, NJ; excluding Maryland (MD)
Affected:
Providers
              Inpatient Hospitals
Affected:
Date Posted: April 27, 2007
Dates of
              Rolling 36 month review look back
Service:
              Section 1886(d) of the Social Security Act (Public Law 98-21; CMS Internet-
              Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity
              Manual (PIM), Chapter 6, Section 6.5.2 (A); IOM, Publication 100-08,
              Medicare Program Integrity Manual, Chapter 13, Sections 13.1, 13.1.1, and
              13.1.3; IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1,
              Section 10; IOM, Publication 100-04, Medicare Claims Processing Manual,
              Chapter 3, Section 40.2.2 (K); Local Coverage Determination Highmark
Issue
              Medicare Services L27548; Medicare Inpatient Fact Sheet; Pepper Report
References
              "Top 20 DRGs for One-day Stays for Short-term Acute Care Hospitals";
              Office of Inspector General (OIG) Report A-01-10-01000 "Analysis of Errors
              IDd in FI 2009 CERT Program"; OIG Report OAI-09-88-00880, "National
              DRG Validation Study Unnecessary Admissions to Hospitals"; OIG Report A-
              03-00-00007, "Review of the HCFA PA Regional Offices Effort to ID
              Overpayments for 1-Day In-Patient Stays"; OIG Report OAI-05-88-00730,
              "National DRG Validation Study: Short Hospitalizations";

				
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