ࡱ>   mbjbjVV 4<<m////Ds/O0$Y,Y,Y,Y,P-P-P-COEOEOEOEOEOEOPrSNEOP-P-P-P-P-EOY,Y,ZO333P-Y,Y,CO3P-CO336S6Y,*ڠ/d/6/OpO0O'6,Sl1hSS6S6SN0P-P-3P-P-P-P-P-EOEO3P-P-P-OP-P-P-P-SP-P-P-P-P-P-P-P-P- : RAC Audit Issues Issue Name: Seizures MS-DRG 100 & 101 (At this time, Medical Necessity is excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia. Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM CH 6.5.3, Section A-C, DRG Validation Medicare Benefit Policy Manual Chapter 1 - Inpatient Hospital Services Covered Under Part A Medicare Program Integrity Manual Chapter 6 - Intermediary MR Guidelines for Specific Services THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM: An Evaluation of the 3-Year Demonstration Medicare Benefit Policy Manual Chapter 6 - Hospital Services Covered Under Part B Medicare Program Integrity Manual Chapter 13 Local Coverage Determinations Issue Name: Eye Procedures MS-DRG 113, 114,115 & 116 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM Ch 6.5.3, Sections A-C DRG Validation Review Medicare Benefit Policy Manual Chapter 1 - Inpatient Hospital Services Covered Under Part A Medicare Program Integrity Manual Chapter 6 - Intermediary MR Guidelines for Specific Services THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM: An Evaluation of the 3-Year Demonstration Medicare Benefit Policy Manual Chapter 6 - Hospital Services Covered Under Part B Medicare Program Integrity Manual Chapter 13 Local Coverage Determinations Issue Name: Ear, Nose, Mouth & Throat Procedures MS DRG 129, 130, 131, 132, 134, 135, 136, 137, 138 & 139 (At this time, Medical Necessity excluded) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia. Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM Ch 6.5.3, Sections A-C DRG Validation Review Medicare Benefit Policy Manual Chapter 1 - Inpatient Hospital Services Covered Under Part A Medicare Program Integrity Manual Chapter 6 - Intermediary MR Guidelines for Specific Services THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM: An Evaluation of the 3-Year Demonstration Medicare Benefit Policy Manual Chapter 6 - Hospital Services Covered Under Part B Medicare Program Integrity Manual Chapter 13 Local Coverage Determinations Issue Name: Nervous System Neoplasms with MCC: MS-DRG 054 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 054, previously DRG's 010 & 011, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Spinal Disorders and Injuries with CC/MCC: MS-DRG 052 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 052, previously DRG 009, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Lymphoma and Nonacute Leukemia with Other O.R. Procedure with CC: MS-DRG 824 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 824, previously DRG's 401 & 402, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Vagina, Cervix, and Vulva Procedures with CC/MCC: MS-DRG 746 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 746, previously DRG 360, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Cholecystectomy Except by Laparoscope without C.D.E. with MCC: MS-DRG 414 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 414, previously DRG 197 and 198, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Prostatectomy with MCC: MS-DRG 665 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 665, previously DRG 306 and 307, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 3) PIM Ch 6.5.3, Section A-C DRG Validation Review Issue Name: Medical Necessity: Infections Description: 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 coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Issue Name: Medical Necessity: Acute Inpatient Admission Neurological Disorders Description: 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 coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Issue Name: Medical Necessity: Acute Inpatient Admission Respiratory Conditions Description: 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 coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Issue Name: Respiratory Infections & Inflammations with MCC: MS-DRG 177 Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 177, previously DRG 079, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS-DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3 coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Respiratory Infections & Inflammations with CC: MS -DRG 178 Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 178, previously DRG 079, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS-DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3 coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Respiratory Infections & Inflammations without CC/MCC: MS -DRG 179 Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 179, previously DRG 080, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS-DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3 coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Respiratory Neoplasms Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRGs 180, 181 & 182, previously DRG 082, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS-DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3 coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Medical Necessity: Vagina, Cervix and Vulva Procedures Description: 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 coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: ICD-9-CM Vol. 1, 2 & 3, coding manuals ICD-9-CM Addendums and Coding Clinics PIM Ch 6.5.3, Section A-C, DRG Validation Review Issue Name: Knee Procedures without Principal Diagnosis of Infection with CC/MCC: MS-DRG 488 Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physican description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 488, previously DRG 503, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Headaches - DRG Validation (At this time, Medical Necessity is excluded from review for MS-DRGs 102) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRGs 102 & 103, previously DRG 564, principal diagnosis, secondary diagnosis and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM CH 6.5.3, Section A-C, DRG Validation Issue Name: Medical Necessity: Cellulitis Description: 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 coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly. According to the RAC demonstration Project Report, HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf, inpatient hospitals received $828.3 million in improper payments. Forty one percent were due to the services rendered in a medically unnecessary setting (often referred to as wrong setting improper payments). These are situations where the beneficiary needed care but did not need to be admitted to the hospital to receive that care. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Issue Name: Infections - DRG Validation (At this time Medical Necessity is excluded from review for MS-DRG 096 and 867) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for the MS-DRGs 094, 095, 096, 867, 868, 869 previously 560, 423, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting DRGs. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2, & 3, coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM Ch 6.5.3, Section A-C, DRG Validation Review Issue Name: Chemo with Acute Leukemia (At this time, Medical Necessity is excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRGs 837, 838 & 839, previously DRG 492, principal diagnosis, secondary diagnosis and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM CH 6.5.3, Section A-C, DRG Validation Issue Name: Gastrointestinal Procedures (At this time, medical necessity will be excluded from this review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRGs 334, 336, 337, 338, 339, 340, 341, 342, 355, 356, 357, 417, 418, 419, 420, 421, 422, 425, previously 567,146, 147, 150, 151, 164, 165, 166, 167, 160, 170, 171, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRGs. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2, & 3, coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM CH.6.5.3, Section A-C, DRG Validation Issue Name: Biopsies of Musculoskeletal System & Connective Tissues w MCC, w CC, w/o CC/MCC (At this time, Medical Necessity excluded from review) Description: DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 477, 478, 479, previously DRG 216, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1,2 &3, coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM Ch. 6.5.3, Sections A-C DRG Validation Review Issue Name: Orthopedic Procedures / Disorders (At this time, Medical Necessity is excluded from this review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRGs 466, 467, 468, 469, 470, 480, 483, 492, 515, 539, 540, 541 previously DRGs 471, 545, 544, 210, 491, 218, 233, 234, 238, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRGs. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM Ch 6.5.3, Section A-C, DRG Validation Review Issue Name: Female Reproductive System Procedures ( At this time Medical Necessity is excluded from review at this time) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRGs 734, 735, 736, 737, 738, 739, 740, 741, 742, 743, previously DRGs 353, 354, 355, 357, 358, 359, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRGs. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM Ch 6.5.3, Section A-C, DRG Validation Review Issue Name: Hip and Femur Procedures Except Major Joint with MCC: MS-DRG 480 (Medical Necessity is excluded from review at this time) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 480, previously DRG 210, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS-DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3 coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3)PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Amputations (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reveiwers will validate for MS-DRGs 474, 475, 476 previously DRG 213, principal diagnosis, secondary diagosis and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1,2 & 3, coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM Ch. 6.5.3, Sections A-C DRG Validation Review Issue Name: Acute Ischemic Stroke with Use of Thrombolytic Agent with MCC: MS-DRG 061 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 061, previously DRG 559, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Ear, Nose, Mouth and Throat Malignancy with CC: MS-DRG 147 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 147, previously DRG 064, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Ear, Nose, Mouth and Throat Malignancy with MCC: MS-DRG 146 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 146, previously DRG 064, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Ventricular Shunt Procedures with MCC: MS-DRG 031 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 031, previously DRG 529 and 530, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Kidney and Ureter Procedures for Non-Neoplasm with CC: MS-DRG 660 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 660, previously DRG 304 and 305, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 3) PIM Ch 6.5.3, Section A-C DRG Validation Review Issue Name: Laparoscopic Cholecystectomy without C.D.E. with CC: MS-DRG 418 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Medicare Benefit Policy Manual Chapter 1 - Inpatient Hospital Services Covered Under Part A Medicare Program Integrity Manual Chapter 6 - Intermediary MR Guidelines for Specific Services THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM: An Evaluation of the 3-Year Demonstration Medicare Benefit Policy Manual Chapter 6 - Hospital Services Covered Under Part B Medicare Program Integrity Manual Chapter 13 Local Coverage Determinations Issue Name: Laparoscopic Cholecystectomy without C.D.E. with MCC: MS-DRG 417 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 417, previously DRG 493, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Co-Surgery not billed with modifier 62 Description: Improper payments exist when two surgeons perform surgery on the same patient; one surgeon added the co-surgeon modifier -62 and the other did not. Provider Type Affected: Physician (Carrier) Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Issue Name: Extracorporeal Photopheresis code 36522 (carrier) Description: CPT Code 36522 cannot be billed without diagnosis codes 202.10 to 202.18, 202.20 to 202.28, or996.83 and 996.85 Provider Type Affected: Physician (Carrier) Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Issue Name: Extracorporeal Photopheresis code 36522 (outpatient) Description: CPT Code 36522 cannot be billed without diagnosis codes 202.10 to 202.18, 202.20 to 202.28, or 996.83 and 996.85 Provider Type Affected: Outpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Issue Name: Chemotherapy Administration Codes Description: When a CPT code reflective of chemotherapy administration is billed, the claim is required to include the code for the corresponding medication administered on the same date to the same patient. Provider Type Affected: Physician (Carrier) Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Issue Name: Ambulance SNF to SNF Transfer (NN Modifier) Description: Ambulance claims for SNF to SNF transfers (modifier NN) are not separately payable under Part B. The SNF discharging the beneficiary to another SNF is financially responsible for the transportation fees. Ambulance providers should seek payment from the transferring SNF. Provider Type Affected: Lab/Ambulance Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Issue Name: Failure to Correctly Bill Codes on the Medically Unlikely Edit List- Carrier Description: Certain codes on the MUE list are being incorrectly billed. An error was made in billing these codes, because more units were billed for same date of service for the same beneficiary by the same provider than what is medically likely and an appropriate modifier was not appended to the claim line. Provider Type Affected: Physician (Carrier) Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Issue Name: Date of Death- Outpatient Description: Medicare does not pay for services or equipment after the beneficiary's date of death. Provider Type Affected: Outpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Issue Name: Date of Death- Carrier Description: Medicare does not pay for services or equipment after the beneficiary's date of death. Provider Type Affected: Physician (Carrier) Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Issue Name: Lymphoma and Leukemia with Major O.R. Procedure with CC: MS-DRG 821 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 821, previously DRG 539 and 540, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Prostatectomy with CC: MS-DRG 666 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 666, previously DRG 306 and 307, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Ventricular Shunt Procedures with MCC: MS-DRG 031 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 031, previously DRG 529 and 530, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Urethral Procedures with CC/MCC: MS-DRG 671 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 671, previously DRG 312, 313 and 314, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Left-sided Cardiac Catheterization Description: CPT Code 93510 (described as:Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous) should only be billed once per patient per date of service. (Excluding claims with Modifiers -73 and -52) Provider Type Affected: Outpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Issue Name: Left-sided Cardiac Catheterization Description: CPT Code 93510 (described as:Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous) should only be billed once per patient per date of service. (Excluding claims with Modifiers -73 and -52 and -26) Provider Type Affected: Physician (Carrier) Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Issue Name: Duplicate Claims DMEPOS Description: Duplicate data fields submitted for DMEPOS claims for the same service, same member, same date of service (not including interim billing or corrected claims) resulting in duplicate payments. Provider Type Affected: DME by Supplier Date of Service: 10/01/2007 - Open States Affected: DME Issues: Suppliers who bill CIGNA Government Services Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.hhs.gov/transmittals/downloads/R492CP.pdf"http://www.cms.hhs.gov/transmittals/downloads/R492CP.pdf HYPERLINK "http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3194"http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3194 Issue Name: Lymphoma and Leukemia with Major O.R. Procedure with MCC: MS-DRG 820 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 820, previously DRG 539 and 540, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Percutaneous Cardiovascular Procedure with Non Drug-Eluting Stent without MCC: MS-DRG 249 Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 249, previously DRG's 555 and 556, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Degenerative Nervous System Disorders with MCC: MS-DRG 056 Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 056, previously DRG 012, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Degenerative Nervous System Disorders without MCC: MS-DRG 057 Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 057, previously DRG 012, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Gastrointestinal Disorders (At this time Medical Necessity is excluded from review for MS-DRG(s) 368, 369, 370, 371, 373, 377, 378, 379, 380, 381, 382, 383, 384, 385, 387, 388, 389, 390, 392, and 395) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRGs 368, 369, 370, 371, 373, 377, 378, 379, 380, 381, 382, 383, 384, 385, 387, 388, 389, 390, 391, 392, 393, 395, previously DRGs 571, 572, 174, 175, 176, 177, 178, 179, 180, 181, 182, 183, 184, 188, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRGs. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM Ch 6.5.3, Section A-C, DRG Validation Review Issue Name: Pharmacy Supply and Dispensing Fees Description: Pharmacy supply and dispensing fees when billed and paid to a DME supplier should be accompanied by an oral anti-cancer, oral anti-emetic, immunosuppressive drug, or inhalation drug. The absence of the drug billed on the same date of service or a denial of the drug represents an overpayment. Claims selected for this New Issue are verified to be allowed paid claims, not adjusted, cancelled, or denied. Provider Type Affected: DME by Supplier Date of Service: 10/01/2007 - Open States Affected: DME Issues: Suppliers who bill CIGNA Government Services Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf"http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf HYPERLINK "http://www.cms.hhs.gov/Transmittals/downloads/R754CP.pdf"http://www.cms.hhs.gov/Transmittals/downloads/R754CP.pdf HYPERLINK "http://www.cms.hhs.gov/mcd/viewlcd_pdf.asp?lcd_id=5007&lcd_version=69&contractor_id=140"http://www.cms.hhs.gov/mcd/viewlcd_pdf.asp?lcd_id=5007&lcd_version=69&contractor_id=140 HYPERLINK "http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=11521&lcd_version=36&show=all"http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=11521&lcd_version=36&show=all HYPERLINK "http://www.cms.hhs.gov/mcd/viewlcd_pdf.asp?lcd_id=11559&lcd_version=23&contractor_id=140"http://www.cms.hhs.gov/mcd/viewlcd_pdf.asp?lcd_id=11559&lcd_version=23&contractor_id=140 HYPERLINK "http://www.cms.hhs.gov/mcd/viewlcd_pdf.asp?lcd_id=11560&lcd_version=34&contractor_id=140"http://www.cms.hhs.gov/mcd/viewlcd_pdf.asp?lcd_id=11560&lcd_version=34&contractor_id=140 Issue Name: Date of Death- DME Description: Medicare does not pay for services or equipment after the beneficiary's date of death. Provider Type Affected: DME by Supplier Date of Service: 10/01/2007 - Open States Affected: DME Issues: Suppliers who bill CIGNA Government Services Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://oig.hhs.gov/publications/docs/workplan/2010/Work_Plan_FY_2010.pdf"http://oig.hhs.gov/publications/docs/workplan/2010/Work_Plan_FY_2010.pdf HYPERLINK "http://www.cms.hhs.gov/manuals/downloads/ge101c02.pdf"http://www.cms.hhs.gov/manuals/downloads/ge101c02.pdf HYPERLINK "http://www.cms.hhs.gov/manuals/downloads/clm104c20.pdf"http://www.cms.hhs.gov/manuals/downloads/clm104c20.pdf HYPERLINK "http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf"http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf HYPERLINK "http://www.cms.hhs.gov/HospitalOutpatientPPS/AU/list.asp" \l "TopOfPage"http://www.cms.hhs.gov/HospitalOutpatientPPS/AU/list.asp#TopOfPage Issue Name: Duplicate Claims - Physician (Carrier) Description: Exact duplicate data fields submitted for physician (carrier) claims for the same service, same member, and same date of service (not including interim billing or corrected claims) resulting in duplicate payments. Provider Type Affected: Physician (Carrier) Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.hhs.gov/transmittals/downloads/R492CP.pdf"http://www.cms.hhs.gov/transmittals/downloads/R492CP.pdf HYPERLINK "http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3194"http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3194 Issue Name: Medical Necessity: Kidney and UTI Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 689. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"http://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Medical Necessity: Other Digestive System Diagnosis Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 393. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"http://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Medical Necessity: Other Vascular Procedures Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 253 and 254. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Informa tion: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"http://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Medical Necessity: Percutaneous Cardiac Procedures Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 249. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"http://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Medical Necessity: Renal Failure Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 682, 683 and 684. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"http://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Medical Necessity: Syncope and Collapse Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 312. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"http://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Medical Necessity: Red Blood Cell Disorder Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 811. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"http://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Medical Necessity: TIA Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 069. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"http://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Medical Necessity: Chest Pain Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 313. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"http://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Medical Necessity: Heart Failure and Shock Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 291, 292 and 293. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"http://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Medical Necessity: Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders with MCC Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 391. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"http://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Medical Necessity: COPD Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 190, 191 and 192. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"http://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Medical Necessity: Nutritional and Misc Metabolic Disorders Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 640. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"http://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Medical Necessity: Circulatory System Disorders Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 314, 315 and 316. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"http://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Medical Necessity: Degenerative Nervous System Disorders Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 056 and 057. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"http://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Medical Necessity: Atherosclerosis Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 302. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"http://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Medical Necessity: Cardiac Arrhythmia Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 308. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: hHYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"ttp://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Medical Necessity: Medical Back Problems Description: RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG 551 and 552. Medicare only pays for inpatient hospital 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. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.gov/manuals/Downloads/bp102c01.pdf"http://www.cms.gov/manuals/Downloads/bp102c01.pdf HYPERLINK "http://www.cms.gov/manuals/downloads/pim83c06.pdf"http://www.cms.gov/manuals/downloads/pim83c06.pdf HYPERLINK "http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf"http://www.cms.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf Issue Name: Other Vascular Procedures without CC/MCC: MS-DRG 254 Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS DRG 254, previously DRG 479, 553 and 554, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H (2007 - 2009) 2) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Other Circulatory System Diagnoses W MCC: MS-DRG 314 Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 314, previously DRG 144, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS-DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1, 2 & 3 coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM Ch. 6.5.3, Section A-C DRG Validation Review Issue Name: Cardiovascular Diseases (At this time Medical Necessity excluded from review for DRG(s) 280, 281, 282, 283, 284, 285, 288, 289, 290, 296, 297, 298, 299, 300, 301, 303, 304, 305, 306, 307, 309, 310 and 311) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRGs 280, 281, 282, 283, 284, 285, 288, 289, 290, 292, 293, 296, 297, 298, 299, 300, 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 311, 313,316, previously DRGs 121, 122, 123, 126, 127, 129, 130, 131, 132, 133, 134, 135, 136, 137, 138, 139, 140, 143, 144, 145, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRGs. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Vol. 1,2 & 3, coding manuals 2) ICD-9-CM Addendums and Coding Clinics 3) PIM Ch. 6.5.3, Sections A-C DRG Validation Review Issue Name: Fulvestrant - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) Description: Each HCPCS unit of fulvestrant represents 25mg. Each 25mg of a dose must be billed with one HCPCS unit per patient, per date of service. Provider Type Affected: Physician (Carrier) Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www1.astrazeneca-us.com/pi/faslodex.pdf"http://www1.astrazeneca-us.com/pi/faslodex.pdf HYPERLINK "http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf"http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf HYPERLINK "http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf"http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf Issue Name: Palonosetron - Dose vs. Units Billed - Underpayment (At this time, Medical Necessity will be excluded from this review) Description: Palonosetron (J2469) represents 25 micrograms (mcg) per unit and should be billed one (1) unit for every 25 mcg per patient. Provider Type Affected: Physician (Carrier) Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.aloxi.com/Common/downloads/PI-FINAL.pdf"http://www.aloxi.com/Common/downloads/PI-FINAL.pdf HYPERLINK "http://www.aloxi.com/reimbursement/Reimbursement/Product.aspx"http://www.aloxi.com/reimbursement/Reimbursement/Product.aspx HYPERLINK "http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf"http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf HYPERLINK "http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf"http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf Issue Name: Minor Bladder Procedures with MCC: MS-DRG 662 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 662, previously DRG 308 and 309, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 3) PIM Ch 6.5.3, Section A-C DRG Validation Review Issue Name: Minor Bladder Procedures without CC/MCC: MS-DRG 664 (At this time, Medical Necessity excluded from review) Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 664, previously DRG 308 and 309, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Provider Type Affected: Inpatient Hospital Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: 1) ICD-9-CM Addendums and Coding Clinics (2007 - 2009) 2) ICD-9-CM Vol. 1, 2 & 3, coding manuals (2007 - 2009) 3) PIM Ch 6.5.3, Section A-C DRG Validation Review Issue Name: Filgrastim (480 mcg) - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) Description: Filgrastim (J1441) represents 480 micrograms (mcg) per unit and should be billed 1 unit for every 480 mcg per patient, per date of service. Provider Type Affected: Physician (Carrier) Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.neupogen.com/pdf/Neupogen_PI.pdf"http://www.neupogen.com/pdf/Neupogen_PI.pdf HYPERLINK "http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf"http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf HYPERLINK "http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf"http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf Issue Name: Dolasetron - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) Description: Dolasetron (J1260) represents 10 milligrams (mg) per unit and should be billed one (1) unit for every 10 mg per patient. Provider Type Affected: Physician (Carrier) Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://products.sanofi-aventis.us/Anzemet_Injection/anzemetinj.pdf"http://products.sanofi-aventis.us/Anzemet_Injection/anzemetinj.pdf HYPERLINK "http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf"http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf HYPERLINK "http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf"http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf Issue Name: Ambulance/transport services provided during an inpatient hospitalization Description: Ambulance transports provided by hospital-based ambulance suppliers to beneficiaries who are in an inpatient stay 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. Provider Type Affected: Lab/Ambulance Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.hhs.gov/manuals/Downloads/bp102c10.pdf"http://www.cms.hhs.gov/manuals/Downloads/bp102c10.pdf HYPERLINK "http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf"http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf HYPERLINK "http://www.cms.hhs.gov/manuals/downloads/clm104c15.pdf"http://www.cms.hhs.gov/manuals/downloads/clm104c15.pdf HYPERLINK "http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=a9afdc8b4bf5cdf1da1854fecb9d0278&rgn=div8&view=text&node=42:2.0.1.2.10.2.35.28&idno=42"http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=a9afdc8b4bf5cdf1da1854fecb9d0278&rgn=div8&view=text&node=42:2.0.1.2.10.2.35.28&idno=42 HYPERLINK "http://oig.hhs.gov/oas/reports/region1/10400513.pdf"http://oig.hhs.gov/oas/reports/region1/10400513.pdf HYPERLINK "http://www.cms.hhs.gov/Transmittals/Downloads/R668CP.pdf"http://www.cms.hhs.gov/Transmittals/Downloads/R668CP.pdf HYPERLINK "http://www.socialsecurity.gov/OP_Home/ssact/title18/1862.htm"http://www.socialsecurity.gov/OP_Home/ssact/title18/1862.htm Issue Name: Rituximab - Dose vs. Units Billed (At this time Medical Necessity will be excluded from this review) Description: Rituximab (J9310) should be billed one (1) unit for every 100 mg per patient. Provider Type Affected: Physician (Carrier) Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.gene.com/gene/products/information/pdf/rituxan-prescribing.pdf"http://www.gene.com/gene/products/information/pdf/rituxan-prescribing.pdf HYPERLINK "http://www.genentechaccesssolutions.com/rituxan/professional/coverage/reimbursement-coding.jsp"http://www.genentechaccesssolutions.com/rituxan/professional/coverage/reimbursement-coding.jsp HYPERLINK "http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf"http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf HYPERLINK "http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf"http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf Issue Name: Leuprolide Acetate (for depot suspension): Dose vs. Units Billed (At this time Medical Necessity will be excluded from this review) Description: Each HCPCS unit of leuprolide represents 7.5mg. A 7.5 mg. injection (1 month formulation) must be billed with 1 unit per patient per date of service, a 22.5 mg. injection (3 month formulation) must be billed with 3 units per patient per date of service, 30 mg. injection (4 month formulation) must be billed with 4 units per patient per date of service and a 45 mg. injection (6 month formulation) must be billed with 6 units per patient per date of service. Provider Type Affected: Physician (Carrier) Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://pitap.abbott.com/lupron7_5mg.pdf"http://pitap.abbott.com/lupron7_5mg.pdf HYPERLINK "http://pitap.abbott.com/lupron3month22_5mg.pdf"http://pitap.abbott.com/lupron3month22_5mg.pdf HYPERLINK "http://pitap.abbott.com/lupron4month30mg.pdf"http://pitap.abbott.com/lupron4month30mg.pdf HYPERLINK "http://products.sanofi-aventis.us/eligard/eligard.pdf"http://products.sanofi-aventis.us/eligard/eligard.pdf HYPERLINK "http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf"http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf HYPERLINK "http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf"http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf Issue Name: Paclitaxel - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) Description: Paclitaxel (J9265) represents 30 mg per unit and should be billed at 1 unit for every 30 mg per patient, per date of service. Provider Type Affected: Physician (Carrier) Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://packageinserts.bms.com/pi/pi_taxol.pdf"http://packageinserts.bms.com/pi/pi_taxol.pdf HYPERLINK "http://www.bdipharma.com/Product%20Inserts/Teva/Onxol.pdf"http://www.bdipharma.com/Product%20Inserts/Teva/Onxol.pdf HYPERLINK "http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf"http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf HYPERLINK "http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf"http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf Issue Name: Cetuximab - Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) Description: Cetuximab (J9055) represents 10 mg per unit and should be billed one (1) unit for every 10 mg per patient. Provider Type Affected: Physician (Carrier) Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.cms.hhs.gov/HCPCSReleaseCodeSets/Downloads/drug2007.pdf"http://www.cms.hhs.gov/HCPCSReleaseCodeSets/Downloads/drug2007.pdf HYPERLINK "http://packageinserts.bms.com/pi/pi_erbitux.pdf"http://packageinserts.bms.com/pi/pi_erbitux.pdf HYPERLINK "http://www.destinationaccess.com/index.aspx?bmscontentpg=erbitux-faqs-medicare"http://www.destinationaccess.com/index.aspx?bmscontentpg=erbitux-faqs-medicare HYPERLINK "http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf"http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf Issue Name: Paclitaxel protein-bound particles - Dose vs. Units Billed (At this time Medical Necessity will be excluded from this review) Description: Paclitaxel protein-bound particles (J9264) represents 1 mg per unit and should be billed at 1 unit for every 1 mg per patient, per date of service. Provider Type Affected: Physician (Carrier) Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: HYPERLINK "http://www.abraxane.com/professional/PDF/Abraxane_Healthcare_Professional_Prescribing_Information.pdf"http://www.abraxane.com/professional/PDF/Abraxane_Healthcare_Professional_Prescribing_Information.pdf HYPERLINK "http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf"http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf HYPERLINK "http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf"http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5718.pdf  ' G 789""]]X]Y]]]56 DEFG ?@AB%&}~#$%&JK01 h@,hPjh@,hPU h@,h@, h@,h @h@,h @5>*CJaJh@,h@,5>*CJaJMbY $Ifgd @BkdZ$IfK$L$'F$ t34Bayt@, $Ifgd 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