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					            CGI Federal (Region B RAC): CMS Approved Audit Issues
                  Released 8/26/09, updated January 18, 2010


        Name           Blood Transfusions
       Number          B000052009
                       Blood Transfusions – should be billed with a maximum of (1)
     Description
                       unit per patient per date of service (outpatient/physician)
     Claim Type        Outpatient Hospital, Physician
   Codes Affected
   Overpayment or
                       Overpayment
   Underpayment
Dates of Service       10/1/2007 - Open
        States         IL, IN, KY, MI, MN, OH, WI
                              CMS Pub 100-04, Ch. 4, § 231.8
                              Program Memorandum Intermediaries, Transmittal A-
Policy Related Links           01-50, April 12, 2001, page 1
                              Federal Register, Vol73, No 223, page 69016

   Date Approved       8/14/2009

        Name           Bronchoscopy Services
      Number           B000062009
                       Bronchoscopy Services - should be billed with a maximum of (1)
     Description
                       unit per patient per date of service (outpatient hospital/physician)
     Claim Type        Outpatient Hospital, Physician
   Codes Affected
  Overpayment or
                       Overpayment
  Underpayment
Dates of Service       10/1/2007 - Open
        States         IL, IN, KY, MI, MN, OH, WI
                              American Medical Association (AMA), Current
                               Procedural Terminology (CPT)
                              Federal Register, Volume 67, No. 251 (12/31/02), page
Policy Related Links
                               80072.
                              American Thoracic Society Coding 2005 Update

   Date Approved       8/14/2009
                  Cardiac arrhythmia & conduction disorders w MCC or w CC DRG
     Name
                  138, MSDRG 308, 309
    Number        B000382009
                  The purpose of MS-DRG Validation is to determine that the principal
                  diagnosis and all secondary diagnoses identified as CCs and MCCs
                  are actually present, correctly sequenced, and coded. When a patient
                  is admitted to the hospital, the condition established after study found
                  to be chiefly responsible for occasioning the admission to the hospital
  Description     should be sequenced as the principal diagnosis. The other diagnosis
                  identified should represent all (MCC/CC) present during the
                  admission that impact the stay. The POA indicator for all diagnoses
                  reported must be coded correctly. Reviewers will validate for MS
                  DRG 308 and/or 309, principal diagnosis, secondary diagnosis, and
                  procedures affecting or potentially affecting the DRG.
  Claim Type      Inpatient
 Codes Affected
Overpayment or
                 Overpayment
 Underpayment
Dates of Service 10/1/2007 - Open
     States       IL, IN, KY, MI, MN, OH, WI
                        ICD-9-CM Coding Manual (for dates of service on claim)
                        ICD-9-CM Addendums and coding clinics
 Policy Related
                        PIM Ch 6.5.3, Section A - C - DRG Validation Review
     Links
                        Present on Admission Indicator Systems Implementation

 Date Approved 12/4/2009

     Name         Chronic Obstructive Pulmonary Disease DRG 88 MSDRG 190, 191
    Number        B000372009
                  The purpose of MS-DRG Validation is to determine that the principal
                  diagnosis and all secondary diagnoses identified as CCs and MCCs
                  are actually present, correctly sequenced, and coded. When a patient
                  is admitted to the hospital, the condition established after study found
                  to be chiefly responsible for occasioning the admission to the hospital
  Description     should be sequenced as the principal diagnosis. The other diagnosis
                  identified should represent all (MCC/CC) present during the
                  admission that impact the stay. The POA indicator for all diagnoses
                  reported must be coded correctly. Reviewers will validate for MS
                  DRG 190 and/or 191, principal diagnosis, secondary diagnosis, and
                  procedures affecting or potentially affecting the DRG.
  Claim Type      Inpatient
 Codes Affected
Overpayment or
               Overpayment
Underpayment
Dates of Service   10/1/2007 - Open
     States        IL, IN, KY, MI, MN, OH, WI
                          ICD-9-CM Coding Manual (for dates of service on claim)
                          ICD-9-CM Addendums and coding clinics
 Policy Related
                          PIM Ch 6.5.3 Section A - C - DRG Validation Review
     Links
                          Present on Admission Indicator Systems Implementation

 Date Approved 12/4/2009



      Name         CSW during Inpatient Hospital
    Number         B000112009
                   CSW during Inpatient Hospital: Clinical Social Workers services
                   (CSW) rendered during an Inpatient Hospital stay are not separately
   Description     payable under Medicare Part B. These services are included in the
                   facility’s Prospective Payment System (PPS). CSW providers are
                   expected to seek reimbursement from the facility.
   Claim Type      CSW Providers
 Codes Affected
Overpayment or
                 Overpayment
 Underpayment
Dates of Service 10/1/2007 - Open
     States        IL, IN, KY, MI, MN, OH, WI
                          Medicare Benefit Policy Manual: Pub 100-02, Ch 15, § 170
 Policy Related
                          CMS Med Learn Matters Article #: SE0439
     Links

 Date Approved 1/5/2010

                   Diseases and Disorders of the Respiratory System DRG 076,079
     Name
                   MSDRG166,167,177,178,179
    Number         B000462009
                   The purpose of MS-DRG Validation is to determine that the principal
                   diagnosis and all secondary diagnoses identified as CCs and MCCs
                   are actually present, correctly sequenced, and coded. When a patient
  Description
                   is admitted to the hospital, the condition established after study found
                   to be chiefly responsible for occasioning the admission to the hospital
                   should be sequenced as the principal diagnosis. The other diagnosis
                  identified should represent all (MCC/CC) present during the
                  admission that impact the stay. The POA indicator for all diagnoses
                  reported must be coded correctly. Reviewers will validate for MS
                  DRG 166,167,177,178, and/or179, principal diagnosis, secondary
                  diagnosis, and procedures affecting or potentially affecting the DRG.
  Claim Type      Inpatient
 Codes Affected
Overpayment or
               Overpayment
Underpayment
Dates of Service 10/1/2007 - Open
     States      IL, IN, KY, MI, MN, OH, WI
                        ICD-9-CM Coding Manual (for dates of service on claim)
                        ICD-9-CM Addendums and coding clinics
                        PIM Ch 6.5.3, Section A - C - DRG Validation Review
                        Present on Admission Indicator Systems Implementation
 Policy Related
                        OIG Report DRG 79 Validation Study Update: Respiratory
     Links
                         Infections And Inflammations, February 1993 (1)
                        OIG Report DRG 79 Validation Study Update: Respiratory
                         Infections And Inflammations, February 1993 (2)

Date Approved 12/4/2009

                  Esophagitis gastroenteritis and misc digest disorder w/MCC DRG
     Name
                  182 MSDRG 391
    Number        B000482009
                  The purpose of MS-DRG Validation is to determine that the principal
                  diagnosis and all secondary diagnoses identified as CCs and MCCs
                  are actually present, correctly sequenced, and coded. When a patient
                  is admitted to the hospital, the condition established after study found
                  to be chiefly responsible for occasioning the admission to the hospital
  Description     should be sequenced as the principal diagnosis. The other diagnosis
                  identified should represent all (MCC/CC) present during the
                  admission that impact the stay. The POA indicator for all diagnoses
                  reported must be coded correctly. Reviewers will validate for MS
                  DRG 391, principal diagnosis, secondary diagnosis, and procedures
                  affecting or potentially affecting the DRG.
  Claim Type      Inpatient
 Codes Affected
Overpayment or
                 Overpayment
 Underpayment
Dates of Service 10/1/2007 - Open
     States        IL, IN, KY, MI, MN, OH, WI
                         ICD-9-CM Coding Manual (for dates of service on claim)
                         ICD-9-CM Addendums and coding clinics
 Policy Related
                         PIM Ch 6.5.3, Section A - C - DRG Validation Review
     Links
                         Present on Admission Indicator Systems Implementation

 Date Approved 12/4/2009

                   Excisional Debridement MSDRG 463, 464, 465, 573, 574, 575, 901,
      Name
                   902, 903 (ICD9 86.22)
    Number         B000392009
                   The purpose of MS-DRG Validation is to determine that the principal
                   diagnosis, procedures and all secondary diagnoses identified as CCs
                   and MCCs are actually present, correctly sequenced, and coded.
                   When a patient is admitted to the hospital, the condition established
                   after study found to be chiefly responsible for occasioning the
                   admission to the hospital should be sequenced as the principal
   Description
                   diagnosis. The other diagnosis identified should represent all
                   (MCC/CC) present during the admission that impact the stay. The
                   POA indicator for all diagnoses reported must be coded correctly.
                   Reviewers will validate for MS DRG 463, 464, 465, 573, 574, 575,
                   901, 902, and/or 903, principal diagnosis, secondary diagnosis, and
                   procedures affecting or potentially affecting the DRG.
   Claim Type      Inpatient
 Codes Affected
Overpayment or
               Overpayment
Underpayment
Dates of Service   10/1/2007 - Open
     States        IL, IN, KY, MI, MN, OH, WI
                         ICD-9-CM Coding Manual (for dates of service on claim)
                         ICD-9-CM Addendums and coding clinics
 Policy Related
                         PIM Ch 6.5.3, Section A - C - DRG Validation Review
     Links
                         Present on Admission Indicator Systems Implementation

 Date Approved 12/4/2009

                   Extensive OR procedure unrelated to Principal Diagnosis DRG 468
      Name
                   MSDRG 981,982,983
    Number         B000452009
                   The purpose of MS-DRG Validation is to determine that the principal
   Description
                   diagnosis and all secondary diagnoses identified as CCs and MCCs
                   are actually present, correctly sequenced, and coded. When a patient
                   is admitted to the hospital, the condition established after study found
                   to be chiefly responsible for occasioning the admission to the hospital
                   should be sequenced as the principal diagnosis. The other diagnosis
                   identified should represent all (MCC/CC) present during the
                   admission that impact the stay. The POA indicator for all diagnoses
                   reported must be coded correctly. Reviewers will validate for MS
                   DRG 981, 982, and/or 983, principal diagnosis, secondary diagnosis,
                   and procedures affecting or potentially affecting the DRG.
   Claim Type      Inpatient
 Codes Affected
Overpayment or
               Overpayment
Underpayment
Dates of Service   10/1/2007 - Open
     States        IL, IN, KY, MI, MN, OH, WI
                         ICD-9-CM Coding Manual (for dates of service on claim)
                         ICD-9-CM Addendums and coding clinics
                         PIM Ch 6.5.3, Section A - C - DRG Validation Review
 Policy Related
                         Present on Admission Indicator Systems Implementation
     Links
                         OIG Report DRG 468: Unrelated Operating Room
                          Procedures, September 1989

 Date Approved 12/4/2009

                   Gastroenteritis Hemorrhage w/MCC wCC DRG 174,MS DRG
      Name
                   377,378,379
    Number         B000362009
                   The purpose of MS-DRG Validation is to determine that the principal
                   diagnosis and all secondary diagnoses identified as CCs and MCCs
                   are actually present, correctly sequenced, and coded. When a patient
                   is admitted to the hospital, the condition established after study found
                   to be chiefly responsible for occasioning the admission to the hospital
   Description     should be sequenced as the principal diagnosis. The other diagnosis
                   identified should represent all (MCC/CC) present during the
                   admission that impact the stay. The POA indicator for all diagnoses
                   reported must be coded correctly. Reviewers will validate for MS
                   DRG 377, 378, and/or 379, principal diagnosis, secondary diagnosis,
                   and procedures affecting or potentially affecting the DRG.
   Claim Type      Inpatient
 Codes Affected
Overpayment or
               Overpayment
Underpayment
Dates of Service   10/1/2007 - Open
     States        IL, IN, KY, MI, MN, OH, WI
                         PIM Ch 6.5.3, Section A - C - DRG Validation Review
 Policy Related
                         Present on Admission Indicator Systems Implementation
     Links

 Date Approved 12/4/2009

                   Heart Failure & Shock w/MCC, w CC, w/o CC/MCC DRG 127 MS-
      Name
                   DRG 291, 292, 293
    Number         B000402009
                   The purpose of MS-DRG Validation is to determine that the principal
                   diagnosis and all secondary diagnoses identified as CCs and MCCs
                   are actually present, correctly sequenced, and coded. When a patient
                   is admitted to the hospital, the condition established after study found
                   to be chiefly responsible for occasioning the admission to the hospital
   Description     should be sequenced as the principal diagnosis. The other diagnosis
                   identified should represent all (MCC/CC) present during the
                   admission that impact the stay. The POA indicator for all diagnoses
                   reported must be coded correctly. Reviewers will validate for MS
                   DRG 291, 292, and/or 293, principal diagnosis, secondary diagnosis,
                   and procedures affecting or potentially affecting the DRG.
   Claim Type      Inpatient
 Codes Affected
Overpayment or
                 Overpayment
 Underpayment
Dates of Service 10/1/2007 - Open
     States        IL, IN, KY, MI, MN, OH, WI
                         ICD-9-CM Coding Manual (for dates of service on claim)
                         ICD-9-CM Addendums and coding clinics
 Policy Related
                         PIM Ch 6.5.3, Section A - C - DRG Validation Review
     Links
                         Present on Admission Indicator Systems Implementation

 Date Approved 12/4/2009

      Name         Hospital to Hospital Transfer
    Number         B000142009
                   Identified MS-DRG inpatient claims improperly reported as a
                   discharge to home rather than as a transfer to another hospital
   Description
                   resulting in an overpayment to the transferring hospital. When a
                   transferring inpatient prospective payment system (IPPS) hospital
                   indicates to Medicare that the patient is being discharged to home,
                   the transferring hospital receives a full MS-DRG payment. In these
                   cases, the transferring hospital should have received a per diem
                   payment rate when transferring a patient to another acute-care
                   facility. An overpayment exists when both hospitals (the transferring
                   hospital and the final discharging hospital) receive full MS-DRG
                   payments.
   Claim Type      Inpatient Hospital
 Codes Affected
Overpayment or
               Overpayment
Underpayment
Dates of Service   10/1/2007 - Open
     States        IL, IN, KY, MI, MN, OH, WI
                         CMS Internet-Only Manual, Medicare Claims Processing
                          Manual, Publication 100-04, Chapter 3, Inpatient Hospital
                          Billing, Sections 20.1.2.4, Transfers, and 40.2.4, IPPS
                          Transfers Between Hospitals
                         CMS Internet-Only Manual, Medicare Claims Processing
                          Manual, Publication 100-04, Chapter 25, Completing and
                          Processing the Form, CMS 1450 Data Set, Section 75.2, FL-
                          17, Patient Status, and FL 18, Condition Codes
                         CMS Change Request 2934, Dated February 6, 2004, New
                          Policy On Acute Hospital Transfer For Patients Who Leave
                          Against Medical Advice
                         CMS Change Request 2716, Dated August 1, 2003, New
                          Common Working File (CWF) Edits to Ensure Accurate
                          Coding and Payments For Discharge And/Or Transfer
                          Policies Under Inpatient Prospective Payment System (IPPS)
 Policy Related
                         CMS Change Request 2891, Dated August 22, 2003, Fiscal
     Links
                          Year (FY) 2004 Inpatient Prospective Payment System
                          (IPPS), Long Term Care Hospital (LTCH), And Other Bill
                          Processing Changes
                         CMS Change Requests 2716 and 2891, Dated January 23,
                          2004, Revising the MCE and IPPS Transfers Between
                          Hospitals Sections Of the Hospital Chapter To Account
                          Changes Described In A-03-065 (CR 2716) and A-03-073
                          (CR 2891)
                         CMS Change Request 3389, Dated July 30, 2004, Revision
                          Of the Common Working File (CWF) Editing For Same Day,
                          Same Provider Acute Care Readmissions (Condition Code
                          B4)
                         Code of Federal Register, 42 CFR 412.4, Discharges and
                          Transfers
                         Federal Register, August 22, 2007, Changes to the Hospital
                         Inpatient Prospective Payment Systems and Fiscal Year 2008
                         Rates: Final Rule
                        Federal Register, October 10, 2007, Changes to the Hospital
                         Inpatient Prospective Payment Systems and Fiscal Year 2008
                         Rates Correction: Final Rule
                        Federal Register, August 19, 2008, Changes to the Hospital
                         Inpatient Prospective Payment Systems and Fiscal Year 2009
                         Rates Correction: Final Rule

 Date Approved 12/10/2009

                  Intracaranial Hemorrhage or Cerebral Infarction DRG 014, MS-DRG
     Name
                  064, 065, 066
    Number        B000412009
                  The purpose of MS-DRG Validation is to determine that the principal
                  diagnosis and all secondary diagnoses identified as CCs and MCCs
                  are actually present, correctly sequenced, and coded. When a patient
                  is admitted to the hospital, the condition established after study found
                  to be chiefly responsible for occasioning the admission to the hospital
  Description     should be sequenced as the principal diagnosis. The other diagnosis
                  identified should represent all (MCC/CC) present during the
                  admission that impact the stay. The POA indicator for all diagnoses
                  reported must be coded correctly. Reviewers will validate for MS
                  DRG 064, 065, and/or 066, principal diagnosis, secondary diagnosis,
                  and procedures affecting or potentially affecting the DRG
  Claim Type      Inpatient
 Codes Affected
Overpayment or
                 Overpayment
 Underpayment
Dates of Service 10/1/2007 - Open
     States       IL, IN, KY, MI, MN, OH, WI
                        ICD-9-CM Coding Manual (for dates of service on claim)
                        ICD-9-CM Addendums and coding clinics
                        PIM Ch 6.5.3, Section A - C - DRG Validation Review
                        Present on Admission Indicator Systems Implementation
                        OIG Report DRG 014: Specific Cerebrovascular Disorders
 Policy Related
                         Except Transient Ischemic Attack, July 1999 (1)
     Links
                        OIG Report DRG 014: Specific Cerebrovascular Disorders
                         Except Transient Ischemic Attack, July 1999 (2)
                        OIG Report DRG 014: Specific Cerebrovascular Disorders
                         Except Transient Ischemic Attack, July 1999 (3)
 Date Approved 12/4/2009

                    Intravenous Infusion Chemotherapy and Non-chemotherapy -
      Name
                    Excessive Units Reported
    Number          B000342009
                    The physician is to report only one “initial” service code unless
                    protocol requires that two separate IV sites must be used. If more
                    than one “initial” service code is billed per day, the carrier shall deny
   Description
                    the second initial service code, unless the patient has to come back
                    for a separately identifiable service on the same day or has two IV
                    lines per protocol.
   Claim Type       Outpatient Hospital / Professional
 Codes Affected
Overpayment or
                 Overpayment
 Underpayment
Dates of Service 10/1/2007 - Open
      States        IL, IN, KY, MI, MN, OH, WI
                          CMS Pub 100-4 Ch. 12, pages 31-32
                          CMS Pub 100-20, Transmittal 419, page 7
                          MLN Matters, MM6349 R/T CR Release Date 12.19.08, page
 Policy Related            4
     Links                MLN Matters, MM3818 R/T CR Release Date 4.15.05, page
                           2
                          CMS Pub 100-04 Ch. 20.4 Reporting of Service Units

 Date Approved 12/16/2009

         Name              IV-Hydration
        Number             B000072009
                           IV-Hydration- should be billed with a maximum number of
      Description
                           units (1) per patient per date of service
      Claim Type           Outpatient Hospital, Physician
    Codes Affected
    Overpayment or
                           Overpayment
    Underpayment
Dates of Service           10/1/2007 - Open
         States            IL, IN, KY, MI, MN, OH, WI
                                  CMS Pub 100-4 Ch. 12, pages 31-32
  Policy Related Links
                                  CMS Pub100-20, Transmittal 419, page 7
                                  MLN Matters, MM6349 R/T CR Release Date
                                   12.19.08, page 4

    Date Approved         8/14/2009

      Name         Kidney & Urinary Tract Infections w/MCC DRG 320, MS-DRG 689
    Number         B000472009
                   The purpose of MS-DRG Validation is to determine that the principal
                   diagnosis and all secondary diagnoses identified as CCs and MCCs
                   are actually present, correctly sequenced, and coded. When a patient
                   is admitted to the hospital, the condition established after study found
                   to be chiefly responsible for occasioning the admission to the hospital
   Description     should be sequenced as the principal diagnosis. The other diagnosis
                   identified should represent all (MCC/CC) present during the
                   admission that impact the stay. The POA indicator for all diagnoses
                   reported must be coded correctly. Reviewers will validate for MS
                   DRG 689, principal diagnosis, secondary diagnosis, and procedures
                   affecting or potentially affecting the DRG.
   Claim Type      Inpatient
 Codes Affected
Overpayment or
               Overpayment
Underpayment
Dates of Service   10/1/2007 - Open
     States        IL, IN, KY, MI, MN, OH, WI
                         ICD-9-CM Coding Manual (for dates of service on claim)
                         ICD-9-CM Addendums and coding clinics
 Policy Related
                         PIM Ch 6.5.3, Section A - C - DRG Validation Review
     Links
                         Present on Admission Indicator Systems Implementation

 Date Approved 12/4/2009

                   Major joint replacement or reattachment w/MCC DRG 544 MS-DRG
      Name
                   469
    Number         B000502009
                   The purpose of MS-DRG Validation is to determine that the principal
                   diagnosis, procedure and all secondary diagnoses identified as CCs
                   and MCCs are actually present, correctly sequenced, and coded.
   Description     When a patient is admitted to the hospital, the condition established
                   after study found to be chiefly responsible for occasioning the
                   admission to the hospital should be sequenced as the principal
                   diagnosis. The other diagnosis identified should represent all
                   (MCC/CC) present during the admission that impact the stay. The
                   POA indicator for all diagnoses reported must be coded correctly.
                   Reviewers will validate for MS DRG 469, principal diagnosis,
                   secondary diagnosis, and procedures affecting or potentially affecting
                   the DRG.
   Claim Type      Inpatient
 Codes Affected
Overpayment or
               Overpayment
Underpayment
Dates of Service   10/1/2007 - Open
     States        IL, IN, KY, MI, MN, OH, WI
                             ICD-9-CM Coding Manual (for dates of service on claim)
                             ICD-9-CM Addendums and coding clinics
 Policy Related
                             PIM Ch 6.5.3, Section A - C - DRG Validation Review
     Links
                             Present on Admission Indicator Systems Implementation

 Date Approved 12/4/2009

      Name         Neulasta
     Number        B000032009
                   Neulasta (HCPCS code J2505) Claims submitted with the total
                   number of milligrams instead 1 unit per 6mg. Claims for J2505
   Description
                   should be submitted so that the units billed represent the number of
                   multiples of 6mg administered, not the total number of mgs.
   Claim Type      Outpatient Hospital, Physician
 Codes Affected
 Overpayment or
                 Overpayment
 Underpayment
Dates of Service 10/1/2007 - Open
      States       IL, IN, KY, MI, MN, OH, WI
                             CMS Manual System, Publication 100-04 Medicare Claims
                              Processing Manual, Transmittal 949 (dated May 12, 2006)
                              CM_C0220_2
                             MLN Matters Number MM5912, Release Date : January 18,
  Policy Related              2008 CM_C0220_3
      Links                  MLN Matters Number MM4380, Release Date : May 12,
                              2006 CM_C0220_4
                             MLN Matters Number MM4380, Release Date : May 12,
                              2006 CM_C0220_4
 Date Approved      9/30/2009

     Name          Nutritional & Metabolic Disorders w/MCC DRG 296, MS-DRG 640
    Number         B000492009
                   The purpose of MS-DRG Validation is to determine that the principal
                   diagnosis and all secondary diagnoses identified as CCs and MCCs
                   are actually present, correctly sequenced, and coded. When a patient
                   is admitted to the hospital, the condition established after study found
                   to be chiefly responsible for occasioning the admission to the hospital
  Description      should be sequenced as the principal diagnosis. The other diagnosis
                   identified should represent all (MCC/CC) present during the
                   admission that impact the stay. The POA indicator for all diagnoses
                   reported must be coded correctly. Reviewers will validate for MS
                   DRG 640, principal diagnosis, secondary diagnosis, and procedures
                   affecting or potentially affecting the DRG.
  Claim Type       Inpatient
 Codes Affected
Overpayment or
                 Overpayment
 Underpayment
Dates of Service 10/1/2007 - Open
     States        IL, IN, KY, MI, MN, OH, WI
                          ICD-9-CM Coding Manual (for dates of service on claim)
                          ICD-9-CM Addendums and coding clinics
                          PIM Ch 6.5.3, Section A - C - DRG Validation Review
                          Present on Admission Indicator Systems Implementation
 Policy Related
                          OIG Report DRG 296: Nutritional and Miscellaneous
     Links
                           Metabolic Disorders, April 1999 (1)
                          OIG Report DRG 296: Nutritional and Miscellaneous
                           Metabolic Disorders, April 1999 (2)

 Date Approved 12/4/2009

        Name              Once in a Lifetime Procedures
      Number              B000022009
                          Once in a Lifetime Procedures – Specified procedures that can
     Description
                          only be performed once in a lifetime per beneficiary.
     Claim Type           Outpatient Hospital, Physician
   Codes Affected
   Overpayment or
                          Overpayment
   Underpayment
Dates of Service            10/1/2007 - Open
        States              IL, IN, KY, MI, MN, OH, WI
                                  CMS Pub 100-08, Ch. 3, § 3.6.
                                  Cahaba GBA Medicare B Newline Article (January
 Policy Related Links
                                   2007)

   Date Approved            9/30/2009

      Name         Oxaliplatin
    Number         B000332009
                   Oxaliplatin represents 0.5 mg per unit and should be billed 1 unit
   Description
                   every 0.5 mg administered per patient per DOS
   Claim Type      Outpatient Hospital
 Codes Affected
Overpayment or
               Overpayment
Underpayment
Dates of Service   10/1/2007 - Open
     States        IL, IN, KY, MI, MN, OH, WI
                            Federal Register/Vol.70, No.217/Thursday, November 10,
                             2005/Rules and Regulations Health and Human Services:
                             Medicare Program Changes to the Hospital Outpatient
                             Prospective Payment System and Calendar Year 2006
                             Payment Rates; Final Rule. CMS Transmittal 786, Change
                             Request 4250
                            CMS Transmittal 786, Change Request 4250
                            CMS Transmittal A-03-051, Change Request 2771
                            CMS National Coverage Determinations Manual, 110.7
                            CMS Pub 100-03 Medicare National Coverage
                             Determinations, Transmittal 38
 Policy Related
                            MLN Matters MM3742, June 15, 2005
     Links
                            The clinical trials identified by CMS:
                            CMS Pub 100-04 Chapter 20.4 Reporting of Service Units
                            CMS Benefit Policy Manual Chapter 15, 50.4.5.
                            CMS Pub 100-04 Claims Processing Manual Transmittal 588
                            The Office of Inspector General (OIG), August, 2009 (A-05-
                             09-0052)
                            The Office of Inspector General (OIG), July, 2009 (A-04-09-
                             06100)
                            Centers for Medicare & Medicaid Services, Hospital
                             Outpatient PPS, April 2008, Addendum B: Line 12255
 Date Approved 12/22/2009

     Name         PreAdmission Testing
    Number        B000352009
                  Diagnostic services (including clinical diagnostic laboratory tests)
                  provided to a beneficiary by the admitting hospital, or by an entity
                  wholly owned or wholly operated by the admitting hospital (or by
  Description     another entity under arrangements with the admitting hospital),
                  within 3 days prior to and including the date of the beneficiary’s
                  admission are deemed to be inpatient services and included in the
                  inpatient payment.
  Claim Type      Outpatient Hospital
 Codes Affected
Overpayment or
                 Overpayment
 Underpayment
Dates of Service 10/1/2007 - Open
     States       IL, IN, KY, MI, MN, OH, WI
                        CMS Internet-Only Manual, Medicare Claims Processing
                         Manual, Publication 100-04, Chapter 3, Inpatient Hospital
                         Billing, Section 40.3, Outpatient Services Treated as Inpatient
                         Services
                        CMS Manual System, Pub 100-04 Medicare Claims
                         Processing, Transmittal 714, Change Request 4089, Subject:
                         Payment Window Edit Corrections within the Common
                         Working File (CWF), Date October 21, 2005
                        CMS Guidance Document, Pub. 100-04 Medicare Claims
                         Processing, Executive Guidance Number 0214, Subject:
                         Modification of Payment Window Edits in the Common
                         Working file (CWF) to Look at Line Item Dates of Service
 Policy Related          (LIDOS) on outpatient Claims, January 17, 2008
     Links              CMS Manual System, Pub 100-04 Medicare Claims
                         Processing, Transmittal 1429. Change Request 5880, Subject:
                         Modification of Payment Window Edits in the Common
                         Working File (CWF) to Look at Line Item Dates of Service
                         (LIDOS) on Outpatient Claims, February 1, 2008.
                        MLN Matters, MM5880, Modification of Payment Window
                         Edits in the Medicare’s Common Working File (CWF) to
                         Look at Line Item Dates of Service (LIDOS) on Outpatient
                         Claims
                        Medicare Learning Network, Provider Inquiry Assistance,
                         Related CR#: 5880, Modification of Payment Window Edits
                         in the Medicare’s Common Working File (CWF) to Look at
                         Line Item Dates of Service(LIDOS) on Outpatient Claims,
                         Date Posted February 5, 2008
                        CMS Internet-Only Manual, Medicare Claims Processing
                         Manual Chapter 25 - Completing and Processing the Form,
                         CMS-1450 Data Set, Section 75.4 - Form Locator 42,
                         Revenue Code.

Date Approved 12/22/2009
                  Separately Paid Ambulance Service during Inpatient Hospitalization
     Name
                  Review
   Number         B000162009
                  Ambulance transports provided by Hospital-Based Ambulance
                  Providers and Suppliers to beneficiaries who are in an inpatient stay
  Description     are the responsibility of the inpatient hospital provider with the
                  exception of transports on the day of admission, day of discharge and
                  during a leave of absence from the inpatient facility.
  Claim Type      Outpatient / Professional
Codes Affected
Overpayment or
Underpayment Overpayment
Dates of Service 10/1/2007 - Open
     States       IL, IN, KY, MI, MN, OH, WI
                        CMS Internet-Only Manual, Medicare Benefit Policy Manual,
                         Publication 100-02, Chapter 10, Ambulance Services, Section
                         10, Ambulance Service and 10.3.3, Separately Payable
                         Ambulance Transport Under Part B Versus Patient
                         Transportation That Is Covered Under A Packaged Hospital
                         Service (Revised 02/20/2009)
                        CMS Internet-Only Manual, Medicare Claims Processing
                         Manual, Publication 100-04, Chapter 3, Inpatient Hospital
                         Billing, Sections 10.4, Payment of Nonphysician Services for
                         Inpatients (Effective 10/1/2003) and 10.5, Hospital Inpatient
 Policy Related          Bundling (Effective 01/03/2006)
     Links              CMS Internet-Only Manual, Medicare Claims Processing
                         Manual, Publication 100-04, Chapter 15, Ambulance,
                         Sections 10.2, Summary of the Benefit and 30.A, Modifier
                         Specific to Ambulance Services (Revised 03/06/2009)
                        Code of Federal Regulations, 42 CFR 410.40, Coverage of
                         Ambulance Services (Revised 02/27/2002)
                        March 17, 2006, Office Of Inspector General (OIG) Report,
                         Medicare Part B Payments for Ambulance Services Rendered
                         to Beneficiaries During Inpatient Stays 2001 Through 2003
                        CMS Change Request 3933, Dated September 2, 2005,
                         Enforcement of Hospital Inpatient Bundling Carrier Denial of
                         Ambulance Claims During An Inpatient Stay (Effective
                         01/03/2006)
                        Section 1862(4) of the Social Security Act, Exclusions from
                         Medicare Coverage

 Date Approved 12/22/2009

     Name         Renal Failure DRG 316, MS-DRG 682, 683, 684
    Number        B000422009
                  The purpose of MS-DRG Validation is to determine that the principal
                  diagnosis and all secondary diagnoses identified as CCs and MCCs
                  are actually present, correctly sequenced, and coded. When a patient
                  is admitted to the hospital, the condition established after study found
                  to be chiefly responsible for occasioning the admission to the hospital
  Description     should be sequenced as the principal diagnosis. The other diagnosis
                  identified should represent all (MCC/CC) present during the
                  admission that impact the stay. The POA indicator for all diagnoses
                  reported must be coded correctly. Reviewers will validate for MS
                  DRG 682, 683, and/or 684, principal diagnosis, secondary diagnosis,
                  and procedures affecting or potentially affecting the DRG.
  Claim Type      Inpatient
 Codes Affected
Overpayment or
                 Overpayment
 Underpayment
Dates of Service 10/1/2007 - Open
     States       IL, IN, KY, MI, MN, OH, WI
                        ICD-9-CM Coding Manual (for dates of service on claim)
                        ICD-9-CM Addendums and coding clinics
 Policy Related
                        PIM Ch 6.5.3, Section A - C - DRG Validation Review
     Links
                        Present on Admission Indicator Systems Implementation

 Date Approved 12/4/2009

                  Respiratory system diagnosis w ventilator support DRG 475, 565,566
     Name
                  MS - DRG 207, 208
    Number        B000512009
                  The purpose of MS-DRG Validation is to determine that the principal
                  diagnosis and all secondary diagnoses identified as CCs and MCCs
  Description     are actually present, correctly sequenced, and coded. When a patient
                  is admitted to the hospital, the condition established after study found
                  to be chiefly responsible for occasioning the admission to the hospital
                   should be sequenced as the principal diagnosis. The other diagnosis
                   identified should represent all (MCC/CC) present during the
                   admission that impact the stay. The POA indicator for all diagnoses
                   reported must be coded correctly. Reviewers will validate for MS
                   DRG 207 and/or 208, principal diagnosis, secondary diagnosis, and
                   procedures affecting or potentially affecting the DRG.
   Claim Type      Inpatient
 Codes Affected
Overpayment or
               Overpayment
Underpayment
Dates of Service   10/1/2007 - Open
     States        IL, IN, KY, MI, MN, OH, WI
                         ICD-9-CM Coding Manual (for dates of service on claim)
                         ICD-9-CM Addendums and coding clinics
                         PIM Ch 6.5.3, Section A - C - DRG Validation Review
 Policy Related
                         Present on Admission Indicator Systems Implementation
     Links
                         OIG Report DRG 475: Respiratory System Diagnosis With
                          Ventilator Support, December 1998

 Date Approved 12/4/2009

      Name         Septicemia DRG 416, 576 MS-DRG 870, 871, 872
    Number         B000442009
                   The purpose of MS-DRG Validation is to determine that the principal
                   diagnosis and all secondary diagnoses identified as CCs and MCCs
                   are actually present, correctly sequenced, and coded. When a patient
                   is admitted to the hospital, the condition established after study found
                   to be chiefly responsible for occasioning the admission to the hospital
   Description     should be sequenced as the principal diagnosis. The other diagnosis
                   identified should represent all (MCC/CC) present during the
                   admission that impact the stay. The POA indicator for all diagnoses
                   reported must be coded correctly. Reviewers will validate for MS
                   DRG 870, 871, and/or 872, principal diagnosis, secondary diagnosis,
                   and procedures affecting or potentially affecting the DRG.
   Claim Type      Inpatient
 Codes Affected
Overpayment or
                 Overpayment
 Underpayment
Dates of Service 10/1/2007 - Open
     States        IL, IN, KY, MI, MN, OH, WI
 Policy Related          ICD-9-CM Coding Manual (for dates of service on claim)
     Links              ICD-9-CM Addendums and coding clinics
                        PIM Ch 6.5.3, Section A - C - DRG Validation Review
                        Present on Admission Indicator Systems Implementation
                        OIG Report DRG 416: Septicemia, August 1989 (1)
                        OIG Report DRG 416: Septicemia, August 1989 (2)

 Date Approved 12/4/2009

     Name         Simple Pneumonia DRG 089, MSDRG 193, 194, 195
    Number        B000432009
                  The purpose of MS-DRG Validation is to determine that the principal
                  diagnosis and all secondary diagnoses identified as CCs and MCCs
                  are actually present, correctly sequenced, and coded. When a patient
                  is admitted to the hospital, the condition established after study found
                  to be chiefly responsible for occasioning the admission to the hospital
  Description     should be sequenced as the principal diagnosis. The other diagnosis
                  identified should represent all (MCC/CC) present during the
                  admission that impact the stay. The POA indicator for all diagnoses
                  reported must be coded correctly. Reviewers will validate for MS
                  DRG 193, 194, and/or 195, principal diagnosis, secondary diagnosis,
                  and procedures affecting or potentially affecting the DRG.
  Claim Type      Inpatient
 Codes Affected
Overpayment or
                 Overpayment
 Underpayment
Dates of Service 10/1/2007 - Open
     States       IL, IN, KY, MI, MN, OH, WI
                        ICD-9-CM Coding Manual (for dates of service on claim)
                        ICD-9-CM Addendums and coding clinics
                        PIM Ch 6.5.3, Section A - C - DRG Validation Review
 Policy Related
                        Present on Admission Indicator Systems Implementation
     Links
                        OIG Report DRG 89: Simple Pneumonia And Pleurisy, June
                         1989

 Date Approved 12/4/2009

      Name         Untimed Codes
     Number        B000042009
                   Untimed Codes – CPT codes (excluding modifiers KX, and 59)
   Description     where the procedure is not defined by a specific timeframe
                   (untimed codes), the provider should enter a one (1) in the units
                   billed column per date of service.
   Claim Type      Outpatient Hospital, Physician
  Codes Affected
 Overpayment or
                Overpayment
 Underpayment
Dates of Service   10/1/2007 - Open
      States       IL, IN, KY, MI, MN, OH, WI
                                CMS Pub 100-04, Transmittal 1019, dated 8.3.06, pages 7-
  Policy Related                 11.
      Links                     CMS Pub 100-04, Ch. 5, § 20.2.

  Date Approved    9/30/2009

       Name            Wheelchair Bundling
      Number           B000092009
                       Billing guidelines for certain wheelchair bases, options, and
    Description        accessories indicate that certain items are components and
                       therefore, not separately payable.
    Claim Type         DME
  Codes Affected
  Overpayment or
                       Overpayment
  Underpayment
Dates of Service       10/1/2007 - Open
       States          IL, IN, KY, MI, MN, OH, WI
                                 National Government Services (NGS) Policy Article for
                                  Wheelchair Options/Accessories (A47229)
                                 National Government Services LCD for Wheelchair
Policy Related Links              Options/Accessories (L27223)
                                 Noridian LCD Policy A19846
                                 CMS Pub 100-03, Ch 1, § 280.1 & 280.3

  Date Approved        11/12/2009

				
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