RAC approved issues by state.doc.doc

RAC approved issues by state(Updated 3-26-10)

State Region/ RAC

Approved Issues (Claim type)

Alabama Region C/ Connolly

For DME provider claims:• Wheelchair bundling • Urological Bundling

For DMEMAC claims:• Budesonide - Dose vs. Billed Units • J7605 Arformoterol, (Brovana) • Q4099 Formoterol fumarate (perforomist)

For outpatient hospital and physician claims:• Blood Transfusions • Untimed Codes • IV Hydration Therapy • Bronchoscopy Services • Pediatric codes exceeding age parameters • Once in a lifetime procedures • J2505: Injection, Pegfilgrastim, 6 mg • Medically Unlikely Edit List • Nebulizer, Demonstration and Evaluation Units Billed • Adenosine - Dose vs. Units billed • Barium Swallow Studies Units Billed

For non-medical necessity DRG validation reviews:• Upper Limb and Toe Amputation for Circulatory System Disorders with MCC: MS-DRG 255 • Cirrhosis and Alcoholic Hepatitis with MCC: MS- DRG 432 • Septicemia without Mechanical Ventilation 96+ Hours without MCC: MS-DRG 872 • Nonextensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC - MS-DRG 989 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987 • Other Respiratory System OR Procedures without CC/MCC: MS-DRG 168 • Extensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983 • Other Respiratory System OR Procedures with CC: MS-DRG 167 • Other Digestive System Diagnoses with CC: MS-DRG 394 • Inflammatory Bowel Disease with CC: MS-DRG 386 • Major Gastrointestinal Disorders and Peritoneal Infections without CC/MCC: MS-DRG 372 • Other Respiratory System OR Procedures with MCC: MS-DRG 166 • Major Small and Large Bowel Procedures without CC/MCC: MS-DRG 331 • Major Small and Large Bowel Procedures with CC: MS-DRG 330 • Major Small and Large Bowel Procedures with MCC: MS- DRG 329 • Major Chest Procedures without CC/MCC: MS-DRG 165 • Major Chest Procedures with MCC: MS-DRG 163 • Major Chest Procedures with CC: MS-DRG 164 • Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207 • Septicemia without Mechanical Ventilation 96+ Hours with MCC: MS-DRG 871 • Extensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981 • Extensive OR Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with CC - MS-DRG 988 • Coagulation Disorders: MS-DRG 813 • Peritoneal Adhesiolysis with MCC: MS-DRG 335 • Nonextensive Burns: MS-DRG 935 • Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674 • Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928 • OR Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876 • Infectious and Parasitic Diseases with OR Procedure without CC/MCC: MS-DRG 855 • Infectious and Parasitic Diseases with OR Procedure with CC: MS-DRG 854 • Postoperative or Posttraumatic Infections with OR Procedure without CC/MCC: MS-DRG 858

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• Infectious and Parasitic Diseases with OR Procedure with MCC: MS-DRG 853 • Postoperative or Posttraumatic Infections with OR Procedure with CC: MS-DRG 857 • Postoperative or Posttraumatic Infections with OR Procedure with MCC: MS-DRG 856 • Wound Debridements for Injuries with CC: MS-DRG 902 • Wound Debridements for Injuries with MCC: MS-DRG 901 • Wound Debridements for Injuries without CC/MCC: MS-DRG 903 • Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673 • Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256 • Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC:

MS-DRG 624 • Cardiac Pacemaker Revision Except Device Replacement without CC/MCC: MS-DRG 262 • Other Circulatory System OR Procedures: MS-DRG 264 • OR Procedure with Diagnoses of Other Contact with Health Services with MCC: MS-DRG 939 • OR Procedure with Diagnoses of Other Contact with Health Services with CC: MS-DRG 940 • Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with MCC: MS-

DRG 463 • Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with CC: MS-

DRG 464 • Skin Graft and/or Debridement for Skin Ulcer or Cellulitis without CC/MCC: MS-DRG 575 • Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with MCC: MS-DRG 576 • Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis without CC/MCC: MS-DRG 578 • Other Hepatobiliary or Pancreas OR Procedures with MCC: MS-DRG 423 • Other Digestive System OR Procedures with CC: MS-DRG 357 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with MCC: MS-DRG

622 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with CC: MS-DRG

623 • Other Digestive System OR Procedures with MCC: MS-DRG 356 • Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders without

CC/MCC: MS-DRG 465 • Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with MCC: MS-DRG 573 • Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC: MS-DRG 574 • Other Vascular Procedures with MCC: MS-DRG 252 • Respiratory system diagnosis with ventilator support < 96 Hours: MS-DRG 208 • Extracranial procedures with CC: MS-DRG 038 • Cardiac defibrillator implant without cardiac catheterization without MCC: MS-DRG 227 • Amputation for circulatory system disorders except upper limb and toe with CC: MS-DRG 240 • Permanent cardiac pacemaker implant with MCC: MS-DRG 242 • Other O.R. procedures for multiple significant trauma with MCC: MS-DRG 957 • Minor small and large bowel procedures with MCC: MS-DRG 344 • Knee procedures without principal diagnosis of infection with CC/MCC: MS-DRG 488 • Fractures of femur with MCC: MS-DRG 533 • Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with MCC: MS-DRG

216• Spinal fusion except cervical with out MCC: MS-DRG 460 • Percutaneous cardiovascular procedure with non drug-eluting stent with MCC or 4+ vessels/stents: MS-DRG

248• Cardiac defibrillator implant with cardiac catheterization with acute myocardial infarction/heart failure/shock

with MCC: MS-DRG 222• Pneumothorax without CC/MCC: MS-DRG 201 • Rehabilitation with CC/MCC: MS-DRG 945 • Major joint replacement or reattachment of lower extremity without MCC: MS-DRG 470 • Psychoses: MS-DRG 885 • Heart failure and shock with MCC: MS-DRG 291 • Pulmonary edema and respiratory failure: MS-DRG 189 • Cardiac defibrillator implant without cardiac catheterization with MCC: MS-DRG 226 • Cholecystectomy except by laparoscope without C.D.E. with CC: MS-DRG 415 • Major cardiovascular procedures with MCC or thoracic aortic aneurysm repair: MS-DRG 237 • HIV with extensive O.R. procedure with MCC: MS-DRG 969 • Extensive burns or full thickness burns with mechanical ventilation 96+ hours without skin graft: MS-DRG

933• Amputation for circulatory system disorders except upper limb and toe with MCC: MS-DRG 239 • Full thickness burn without skin graft or inhalation injury: MS-DRG 934 • Permanent cardiac pacemaker implant with CC: MS-DRG 243 • Percutaneous cardiovascular procedure with drug-eluting stent with MCC or 4+ Vessels/Stents: MS-DRG

246• Other vascular procedures with CC: MS-DRG 253 • Other female reproductive system O.R. procedures with CC/MCC: MS-DRG 749


• Other O.R. procedures of the blood and blood-forming organs with CC: MS-DRG 803 • Lymphoma and nonacute leukemia with other O.R. procedure with MCC: MS-DRG 823 • Other circulatory system diagnoses with CC: MS-DRG 315 • Amputation of lower limb for endocrine, nutritional, and metabolic dsorders with CC: MS-DRG 617 • Myeloproliferative disorders or poorly differentiated neoplasms with other O.R. procedure with CC/MCC: MS-

DRG 829• Knee procedures with principal diagnosis of infection with CC: MS-DRG 486 • O.R. procedure with diagnoses of other contact with health services without CC/MCC: MS-DRG 941 • Skin graft and/or debridement except for skin ulcer or cellulitis with CC: MS-DRG 577 • Other digestive system O.R. procedures without CC/MCC: MS-DRG 358 • Other ear, nose, mouth and throat O.R. procedures with CC/MCC: MS-DRG 133 • Other hepatobiliary or pancreas O.R. procedures with CC: MS-DRG 424 • Amputation of lower limb for endocrine, nutritional, and metabolic disorders with MCC: MS-DRG 616 • Other kidney and urinary tract procedures without CC/MCC: MS-DRG 675 • Other male reproductive system O.R. procedures except malignancy with CC/MCC: MS-DRG 717 .

Peripheral/cranial nerve and other nervous system procedures with CC or peripheral neurostimulator: MS-DRG 041

• Major bladder procedures with CC: MS-DRG 654 • Stomach, esophageal and duodenal procedures with CC: MS-DRG 327 • Rectal resection with CC: MS-DRG 333 • Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with CC: MS-DRG 217

Alaska Region D/HDI

For Part A outpatient and Part B claims:• Neulasta (HCPCS code J2505) • Newborn Pediatric CPT Codes Billed for Patients Exceeding Age Limit • Once in a Lifetime • Excessive Units—Untimed Codes • Excessive Units—Blood Transfusions • Excessive Units—Bronchoscopy • Excessive Units—IV Hydration • Global vs. TC/PC • Facility vs. Non-Facility Reimbursement (Inpatient) • SNF Consolidated Billing • Anesthesia Care Package E&M Services • NCCI Edits • Hospice Related Services – B • TC of Radiology • Not a New Patient - Providers are only allowed to bill the CPT codes for New Patient visits if the patient has

not received any professional services from the physician or physician group practice within the previous 3 years.

• OP services within 72 hours of admit • Acute Hospital Readmissions without condition code B4 or 42 • Incorrect patient status-IRF • Medically unlikely edits (Part A Outpatient, Part B) • CSW During Inpatient

For DMEMAC claims:• Urological bundling • Wheelchair Bundling • Knee Orthotic Bundling • PEN supplies more than one time a day • Infusion Pump Denied/Accessories & Drug Codes should be denied • DMEPOS while patient is in a Covered Part A Inpatient Hospital Stay • SNF Consolidated Billing • A4221 Excessive Units • Prosthetic Bundling • DME while in Hospice • Medical Supplies and Home Health Consolidated billing • Date of Death-DME • Medically unlikely edits • DME duplicates • CPM device after three weeks

For non-medical necessity DRG-validation inpatient claims:• Amputations ( MS-DRGs 239-241, 255-257, 474-476, 616-618) • Blood & immunological procedures ( MS-DRGs 799, 800, 801, 802, 803, 804) • Burns ( MS-DRGs 927, 928, 929, 933, 934, 935) • Cardiac procedures ( MS-DRGs 034-036, 215, 222-227, 231-236, 242-249, 258-262, 265, 286-287) • Cardiovascular diseases ( MS-DRGs 280-285, 288-293, 296-311, 313-316) • Cardiovascular procedures ( MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 253, 254, 263, 264)


• Blood & immunological disorders ( MS-DRGs 808, 809, 810, 811, 812, 813, 815, 815, 816) • Ear, nose, mouth & throat procedures ( MS-DRGs 129-139) • Endocrine, nutritional & metabolic disorders ( MS-DRGs 637-645) • Eye procedures ( MS-DRGs 113-117) • Female reproductive system procedures ( MS-DRGs 734-750) • Gastrointestinal disorders ( MS-DRGs 368-395 and 432-446) • Gastrointestinal procedures ( MS-DRGs 326-358, 405-415, 417-425) • Health status factors ( MS-DRGs 939, 940, 941, 945-951) • Infection ( MS-DRGs 094, 095, 096, 853, 854, 855, 867, 868, 869) • Kidney & urinary tract disorders ( MS-DRGs 682-690, 695-700) • Kidney & urinary tract procedures ( MS-DRGs 652-675 and 691, 692, 693, 694, 694) • Male reproductive system procedures ( MS-DRGs 707-718) • Malignant breast disorders (MS DRGs 597, 598, 599 ) • MDC 04 respiratory ( MS-DRGs 163-168, 175-208) • Mental diseases & disorders ( MS-DRGs 876, 880-887, 894-897) • Multiple significant trauma procedures ( MS-DRGs 955, 956, 957, 958, 959, 963, 964, 965) • Neoplasm ( MS-DRGs 837-849) • Neoplasm surgery ( MS-DRGs 837-849) • Nervous system disorders (MS-DRGS 052-074, 077-086, 088-093 and 097-103) • Nervous system procedures ( MS-DRGs 020-033 and 037-042) • OR procedure unrelated to principal diagnosis (MS DRGs 981 -989) • Postoperative or post-traumatic infection (MS DRGs 856, 857, 858, 862, 863 ) • Procedures for injuries ( MS-DRGs 907, 908, 909) • Septicemia ( MS-DRGs 870, 871, 872) • Skin graft & connective tissue procedures ( MS-DRGs 463-465, 477-479, 500-502, 515-517, 573-581,

622-624, 901-905)• Spinal fusion ( MS-DRGs 453, 454, 455, 456, 457, 458, 459, 460, 471, 472, 473, 490, 491) • Transplants ( MS-DRGs 001, 002, 003, 004, 005, 006, 007, 008, 009, 010, 011, 012, 013) • Pregnancy, Childbirth & Peruperium (MS-DRGs 765, 766, 767, 768, 769, 770, 771, 774, 775, 776, 777, 778,

779, 780, 781, 782• Breast Procedures (MSDRGS 582, 583, 584, 585, 600, 601) • Cardiovascular, Other (MSDRGS 294, 295, 312) • Ear, Nose, Mouth & Throat Disorders (MSDRGS 146-159) • Endocrine, Nutritional & Metabolic Procedures (MSDRGS 614, 615, 619, 620, 621, 625, 626, 627, 628, 629,

630)• Eye Disorders (MSDRGS 121-125) • Female Reproductive System Disorders (MSDRGS 754,-761) • HIV Infections (MSDRGS 969, 970, 974, 975, 976, 977) • Infection, Other (MSDRGS 075, 076, 864, 865, 866) • Joint Procedures (MSDRGS 461, 462, 466-470, 480-489, 492-494, 498, 499, 503-514, 535, 536, 906) • Male Reproductive System Disorders (MSDRGS 754-761) • M usculoskeletal Disorders (MSDRGS 539, 540, 541, 545-558, 564, 565, 566) • Musculoskeletal Fractures (MSDRGS 495, 496, 497, 533, 534, 537, 538, 542, 543, 544, 562, 563) • Skin Disorders (MSDRGS 592, 593, 594, 595, 596, 602, 603, 604, 605, 606, 607) • Disorders Related to Injuries, Toxicity (MSDRGS 913, 914, 915, 916, 917, 918, 919, 920, 921, 922, 923)

Arizona Region D/HDI






For non-medical necessity DRG-validation inpatient claims:• Amputations ( MS-DRGs 239-241, 255-257, 474-476, 616-618) • Blood & immunological procedures ( MS-DRGs 799, 800, 801, 802, 803, 804) • Burns ( MS-DRGs 927, 928, 929, 933, 934, 935) • Cardiac procedures ( MS-DRGs 034-036, 215, 222-227, 231-236, 242-249, 258-262, 265, 286-287) • Cardiovascular diseases ( MS-DRGs 280-285, 288-293, 296-311, 313-316) • Cardiovascular procedures ( MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 253, 254, 263, 264) • Blood & immunological disorders ( MS-DRGs 808, 809, 810, 811, 812, 813, 815, 815, 816) • Ear, nose, mouth & throat procedures ( MS-DRGs 129-139) • Endocrine, nutritional & metabolic disorders ( MS-DRGs 637-645) • Eye procedures ( MS-DRGs 113-117) • Female reproductive system procedures ( MS-DRGs 734-750) • Gastrointestinal disorders ( MS-DRGs 368-395 and 432-446) • Gastrointestinal procedures ( MS-DRGs 326-358, 405-415, 417-425) • Health status factors ( MS-DRGs 939, 940, 941, 945-951) • Infection ( MS-DRGs 094, 095, 096, 853, 854, 855, 867, 868, 869) • Kidney & urinary tract disorders ( MS-DRGs 682-690, 695-700) • Kidney & urinary tract procedures ( MS-DRGs 652-675 and 691, 692, 693, 694, 694) • Male reproductive system procedures ( MS-DRGs 707-718) • Malignant breast disorders (MS DRGs 597, 598, 599 ) • MDC 04 respiratory ( MS-DRGs 163-168, 175-208) • Mental diseases & disorders ( MS-DRGs 876, 880-887, 894-897) • Multiple significant trauma procedures ( MS-DRGs 955, 956, 957, 958, 959, 963, 964, 965) • Neoplasm ( MS-DRGs 837-849) • Neoplasm surgery ( MS-DRGs 837-849) • Nervous system disorders (MS-DRGS 052-074, 077-086, 088-093 and 097-103) • Nervous system procedures ( MS-DRGs 020-033 and 037-042) • OR procedure unrelated to principal diagnosis (MS DRGs 981 -989) • Postoperative or post-traumatic infection (MS DRGs 856, 857, 858, 862, 863 ) • Procedures for injuries ( MS-DRGs 907, 908, 909) • Septicemia ( MS-DRGs 870, 871, 872) • Skin graft & connective tissue procedures ( MS-DRGs 463-465, 477-479, 500-502, 515-517, 573-581,



630)• Eye Disorders (MSDRGS 121-125) • Female Reproductive System Disorders (MSDRGS 754,-761) • HIV Infections (MSDRGS 969, 970, 974, 975, 976, 977) • Infection, Other (MSDRGS 075, 076, 864, 865, 866) • Joint Procedures (MSDRGS 461, 462, 466-470, 480-489, 492-494, 498, 499, 503-514, 535, 536, 906) • Male Reproductive System Disorders (MSDRGS 754-761) • M usculoskeletal Disorders (MSDRGS 539, 540, 541, 545-558, 564, 565, 566) • Musculoskeletal Fractures (MSDRGS 495, 496, 497, 533, 534, 537, 538, 542, 543, 544, 562, 563) • Skin Disorders (MSDRGS 592, 593, 594, 595, 596, 602, 603, 604, 605, 606, 607)


• Disorders Related to Injuries, Toxicity (MSDRGS 913, 914, 915, 916, 917, 918, 919, 920, 921, 922, 923)

Arkansas Region C/ Connolly



For outpatient hospital and physician claims:• Medically Unlikely Edit List • Nebulizer, Demonstration and Evaluation Units Billed • Adenosine - Dose vs. Units billed • Barium Swallow Studies Units Billed

For non-medical necessity DRG validation reviews:• Peritoneal Adhesiolysis with MCC: MS-DRG 335 • Nonextensive Burns: MS-DRG 935 • Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674 • Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928 • OR Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876 • Infectious and Parasitic Diseases with OR Procedure without CC/MCC: MS-DRG 855 • Infectious and Parasitic Diseases with OR Procedure with CC: MS-DRG 854 • Postoperative or Posttraumatic Infections with OR Procedure without CC/MCC: MS-DRG 858 • Infectious and Parasitic Diseases with OR Procedure with MCC: MS-DRG 853 • Postoperative or Posttraumatic Infections with OR Procedure with CC: MS-DRG 857 • Postoperative or Posttraumatic Infections with OR Procedure with MCC: MS-DRG 856 • Wound Debridements for Injuries with CC: MS-DRG 902 • Wound Debridements for Injuries with MCC: MS-DRG 901 • Wound Debridements for Injuries without CC/MCC: MS-DRG 903 • Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673 • Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256 • Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC:






CC/MCC: MS-DRG 465 • Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with MCC: MS-DRG 573 • Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC: MS-DRG 574 • Other Vascular Procedures with MCC: MS-DRG 252 • Respiratory system diagnosis with ventilator support < 96 Hours: MS-DRG 208 • Extracranial procedures with CC: MS-DRG 038 • Cardiac defibrillator implant without cardiac catheterization without MCC: MS-DRG 227 • Amputation for circulatory system disorders except upper limb and toe with CC: MS-DRG 240 • Permanent cardiac pacemaker implant with MCC: MS-DRG 242 • Other O.R. procedures for multiple significant trauma with MCC: MS-DRG 957 • Minor small and large bowel procedures with MCC: MS-DRG 344 • Knee procedures without principal diagnosis of infection with CC/MCC: MS-DRG 488 • Fractures of femur with MCC: MS-DRG 533


• Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with MCC: MS-DRG 216

• Spinal fusion except cervical with out MCC: MS-DRG 460 • Percutaneous cardiovascular procedure with non drug-eluting stent with MCC or 4+ vessels/stents: MS-DRG




246• Other vascular procedures with CC: MS-DRG 253 • Other female reproductive system O.R. procedures with CC/MCC: MS-DRG 749 • Other O.R. procedures of the blood and blood-forming organs with CC: MS-DRG 803 • Lymphoma and nonacute leukemia with other O.R. procedure with MCC: MS-DRG 823 • Other circulatory system diagnoses with CC: MS-DRG 315 • Amputation of lower limb for endocrine, nutritional, and metabolic dsorders with CC: MS-DRG 617 • Myeloproliferative disorders or poorly differentiated neoplasms with other O.R. procedure with CC/MCC: MS-

DRG 829• Knee procedures with principal diagnosis of infection with CC: MS-DRG 486 • O.R. procedure with diagnoses of other contact with health services without CC/MCC: MS-DRG 941 • Skin graft and/or debridement except for skin ulcer or cellulitis with CC: MS-DRG 577 • Other digestive system O.R. procedures without CC/MCC: MS-DRG 358 • Other ear, nose, mouth and throat O.R. procedures with CC/MCC: MS-DRG 133 • Other hepatobiliary or pancreas O.R. procedures with CC: MS-DRG 424 • Amputation of lower limb for endocrine, nutritional, and metabolic disorders with MCC: MS-DRG 616 • Other kidney and urinary tract procedures without CC/MCC: MS-DRG 675 • Other male reproductive system O.R. procedures except malignancy with CC/MCC: MS-DRG 717 .• Peripheral/cranial nerve and other nervous system procedures with CC or peripheral neurostimulator: MS-

DRG 041• Major bladder procedures with CC: MS-DRG 654 • Stomach, esophageal and duodenal procedures with CC: MS-DRG 327 • Rectal resection with CC: MS-DRG 333 • Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with CC: MS-DRG 217

California Region D/HDI



• OP services within 72 hours of admit • Acute Hospital Readmissions without condition code B4 or 42 • Incorrect patient status-IRF • Medically unlikely edits (Part A Outpatient, Part B)


• CSW During Inpatient





630)• Eye Disorders (MSDRGS 121-125) • Female Reproductive System Disorders (MSDRGS 754,-761) • HIV Infections (MSDRGS 969, 970, 974, 975, 976, 977) • Infection, Other (MSDRGS 075, 076, 864, 865, 866) • Joint Procedures (MSDRGS 461, 462, 466-470, 480-489, 492-494, 498, 499, 503-514, 535, 536, 906) • Male Reproductive System Disorders (MSDRGS 754-761) • M usculoskeletal Disorders (MSDRGS 539, 540, 541, 545-558, 564, 565, 566) • Musculoskeletal Fractures (MSDRGS 495, 496, 497, 533, 534, 537, 538, 542, 543, 544, 562, 563)


• Skin Disorders (MSDRGS 592, 593, 594, 595, 596, 602, 603, 604, 605, 606, 607) • Disorders Related to Injuries, Toxicity (MSDRGS 913, 914, 915, 916, 917, 918, 919, 920, 921, 922, 923)

Colorado Region C/ Connolly



For non-medical necessity DRG validation reviews:• Upper Limb and Toe Amputation for Circulatory System Disorders with MCC: MS-DRG 255 • Cirrhosis and Alcoholic Hepatitis with MCC: MS- DRG 432 • Septicemia without Mechanical Ventilation 96+ Hours without MCC: MS-DRG 872 • Nonextensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC - MS-DRG 989 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987 • Other Respiratory System OR Procedures without CC/MCC: MS-DRG 168 • Extensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983 • Other Respiratory System OR Procedures with CC: MS-DRG 167 • Other Digestive System Diagnoses with CC: MS-DRG 394 • Inflammatory Bowel Disease with CC: MS-DRG 386 • Major Gastrointestinal Disorders and Peritoneal Infections without CC/MCC: MS-DRG 372 • Other Respiratory System OR Procedures with MCC: MS-DRG 166 • Major Small and Large Bowel Procedures without CC/MCC: MS-DRG 331 • Major Small and Large Bowel Procedures with CC: MS-DRG 330 • Major Small and Large Bowel Procedures with MCC: MS- DRG 329 • Major Chest Procedures without CC/MCC: MS-DRG 165 • Major Chest Procedures with MCC: MS-DRG 163 • Major Chest Procedures with CC: MS-DRG 164 • Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207 • Septicemia without Mechanical Ventilation 96+ Hours with MCC: MS-DRG 871 • Extensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981 • Extensive OR Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with CC - MS-DRG 988 • Coagulation Disorders: MS-DRG 813 • Peritoneal Adhesiolysis with MCC: MS-DRG 335 • Nonextensive Burns: MS-DRG 935 • Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674 • Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928 • OR Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876 • Infectious and Parasitic Diseases with OR Procedure without CC/MCC: MS-DRG 855 • Infectious and Parasitic Diseases with OR Procedure with CC: MS-DRG 854 • Postoperative or Posttraumatic Infections with OR Procedure without CC/MCC: MS-DRG 858 • Infectious and Parasitic Diseases with OR Procedure with MCC: MS-DRG 853 • Postoperative or Posttraumatic Infections with OR Procedure with CC: MS-DRG 857 • Postoperative or Posttraumatic Infections with OR Procedure with MCC: MS-DRG 856 • Wound Debridements for Injuries with CC: MS-DRG 902 • Wound Debridements for Injuries with MCC: MS-DRG 901 • Wound Debridements for Injuries without CC/MCC: MS-DRG 903 • Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673 • Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256 • Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC:



DRG 464 • Skin Graft and/or Debridement for Skin Ulcer or Cellulitis without CC/MCC: MS-DRG 575 • Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with MCC: MS-DRG 576 • Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis without CC/MCC: MS-DRG 578 • Other Hepatobiliary or Pancreas OR Procedures with MCC: MS-DRG 423 • Other Digestive System OR Procedures with CC: MS-DRG 357


• Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with MCC: MS-DRG 622

• Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with CC: MS-DRG 623

• Other Digestive System OR Procedures with MCC: MS-DRG 356 • Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders without









For outpatient hospital and physician claims:• Once in a lifetime procedures


• J2505: Injection, Pegfilgrastim, 6 mg • Medically Unlikely Edit List • Nebulizer, Demonstration and Evaluation Units Billed • Adenosine - Dose vs. Units billed • Barium Swallow Studies Units Billed

Connecticut Region A/DCS

For DME supplier claims:• Pharmacy Supply and Dispensing Fees • Wheelchair Bundling • Urological Bundling • Wheel Attachment with New Non-Wheeled Walker • Headrest with a Power Operated Vehicle or a Power Wheelchair with a Captain's Chair Seat • Multiple DME Rentals within a Month • Prosthetic Additions with Initial or Preparatory Knee Prosthesis • Lower Limb Suction Value Prosthesis • Solid Insert with Seat or Back Wheelchair Cushions • Oxygen Accessories

For ambulance provider claims:• Ambulance Unbundled Services During an Inpatient Hospital Stay

For non-medical necessity DRG-validation inpatient claims:

• MS-DRG Validation for MS-DRGs with Ventilator Support of 96+ Hours (At this time, Medical Necessity is excluded from review.)

• MS-DRG Validation for MS-DRG 189 Pulmonary Edema & Respiratory Failure (At this time, Medical Necessity is excluded from review.)

• MS-DRG Validation for MS-DRGs for Tracheostomy (At this time, Medical Necessity is excluded from review.)

• MS-DRG validation for cardiac procedures

• MS-DRG validation for major large and small bowel procedures

• MS-DRG validation for intracranial hemorrhage or cerebral infarction Delaware Region

A/DCSFor DME supplier claims:• Pharmacy Supply and Dispensing Fees • Wheelchair Bundling • Urological Bundling • Wheel Attachment with New Non-Wheeled Walker • Headrest with a Power Operated Vehicle or a Power Wheelchair with a Captain's Chair Seat • Multiple DME Rentals within a Month • Prosthetic Additions with Initial or Preparatory Knee Prosthesis • Lower Limb Suction Value Prosthesis • Solid Insert with Seat or Back Wheelchair Cushions • Oxygen Accessories








• MS-DRG validation for intracranial hemorrhage or cerebral infarction District of Columbia

Region A/DCS

For DME supplier claims:• Pharmacy Supply and Dispensing Fees • Wheelchair Bundling • Urological Bundling • Wheel Attachment with New Non-Wheeled Walker


• Headrest with a Power Operated Vehicle or a Power Wheelchair with a Captain's Chair Seat • Multiple DME Rentals within a Month • Prosthetic Additions with Initial or Preparatory Knee Prosthesis • Lower Limb Suction Value Prosthesis • Solid Insert with Seat or Back Wheelchair Cushions • Oxygen Accessories








• MS-DRG validation for intracranial hemorrhage or cerebral infarction

Florida Region C/ Connolly



For clinical social worker claims:• Clinical Social Worker (CSW) Services

For outpatient hospital and physician claims:• Blood tranfusions • Untimed codes • IV hydration therapy • Once in a lifetime procedures • Pediatric codes exceeding age parameters • J2505: Injection, Pegfilgrastim, 6 mg • Medically Unlikely Edit List • Nebulizer, Demonstration and Evaluation Units Billed • Adenosine - Dose vs. Units billed • Barium Swallow Studies Units Billed

For non-medical necessity DRG validation reviews:• Upper Limb and Toe Amputation for Circulatory System Disorders with MCC: MS-DRG 255 • Cirrhosis and Alcoholic Hepatitis with MCC: MS- DRG 432 • Septicemia without Mechanical Ventilation 96+ Hours without MCC: MS-DRG 872 • Nonextensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC - MS-DRG 989 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987 • Other Respiratory System OR Procedures without CC/MCC: MS-DRG 168 • Extensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983 • Other Respiratory System OR Procedures with CC: MS-DRG 167 • Other Digestive System Diagnoses with CC: MS-DRG 394 • Inflammatory Bowel Disease with CC: MS-DRG 386 • Major Gastrointestinal Disorders and Peritoneal Infections without CC/MCC: MS-DRG 372 • Other Respiratory System OR Procedures with MCC: MS-DRG 166 • Major Small and Large Bowel Procedures without CC/MCC: MS-DRG 331 • Major Small and Large Bowel Procedures with CC: MS-DRG 330 • Major Small and Large Bowel Procedures with MCC: MS- DRG 329 • Major Chest Procedures without CC/MCC: MS-DRG 165 • Major Chest Procedures with MCC: MS-DRG 163 • Major Chest Procedures with CC: MS-DRG 164 • Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207


• Septicemia without Mechanical Ventilation 96+ Hours with MCC: MS-DRG 871 • Extensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981 • Extensive OR Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with CC - MS-DRG 988 • Coagulation Disorders: MS-DRG 813 • Peritoneal Adhesiolysis with MCC: MS-DRG 335 • Nonextensive Burns: MS-DRG 935 • Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674 • Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928 • OR Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876 • Infectious and Parasitic Diseases with OR Procedure without CC/MCC: MS-DRG 855 • Infectious and Parasitic Diseases with OR Procedure with CC: MS-DRG 854 • Postoperative or Posttraumatic Infections with OR Procedure without CC/MCC: MS-DRG 858 • Infectious and Parasitic Diseases with OR Procedure with MCC: MS-DRG 853 • Postoperative or Posttraumatic Infections with OR Procedure with CC: MS-DRG 857 • Postoperative or Posttraumatic Infections with OR Procedure with MCC: MS-DRG 856 • Wound Debridements for Injuries with CC: MS-DRG 902 • Wound Debridements for Injuries with MCC: MS-DRG 901 • Wound Debridements for Injuries without CC/MCC: MS-DRG 903 • Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673 • Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256 • Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC:









with MCC: MS-DRG 222• Pneumothorax without CC/MCC: MS-DRG 201 • Rehabilitation with CC/MCC: MS-DRG 945 • Major joint replacement or reattachment of lower extremity without MCC: MS-DRG 470 • Psychoses: MS-DRG 885 • Heart failure and shock with MCC: MS-DRG 291 • Pulmonary edema and respiratory failure: MS-DRG 189


• Cardiac defibrillator implant without cardiac catheterization with MCC: MS-DRG 226 • Cholecystectomy except by laparoscope without C.D.E. with CC: MS-DRG 415 • Major cardiovascular procedures with MCC or thoracic aortic aneurysm repair: MS-DRG 237 • HIV with extensive O.R. procedure with MCC: MS-DRG 969 • Extensive burns or full thickness burns with mechanical ventilation 96+ hours without skin graft: MS-DRG





Georgia Region C/ Connolly



For outpatient hospital and physician claims:• Blood tranfusions • Untimed codes • IV hydration therapy • Bronchoscopy services • Once in a lifetime procedures • J2505: Injection, Pegfilgrastim, 6 mg • Pediatric codes exceeding age parameters • Medically Unlikely Edit List • Nebulizer, Demonstration and Evaluation Units Billed • Adenosine - Dose vs. Units billed • Barium Swallow Studies Units Billed

For non-medical necessity DRG validation reviews:• Upper Limb and Toe Amputation for Circulatory System Disorders with MCC: MS-DRG 255 • Cirrhosis and Alcoholic Hepatitis with MCC: MS- DRG 432 • Septicemia without Mechanical Ventilation 96+ Hours without MCC: MS-DRG 872 • Nonextensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC - MS-DRG 989 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987 • Other Respiratory System OR Procedures without CC/MCC: MS-DRG 168 • Extensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983 • Other Respiratory System OR Procedures with CC: MS-DRG 167 • Other Digestive System Diagnoses with CC: MS-DRG 394 • Inflammatory Bowel Disease with CC: MS-DRG 386 • Major Gastrointestinal Disorders and Peritoneal Infections without CC/MCC: MS-DRG 372 • Other Respiratory System OR Procedures with MCC: MS-DRG 166


• Major Small and Large Bowel Procedures without CC/MCC: MS-DRG 331 • Major Small and Large Bowel Procedures with CC: MS-DRG 330 • Major Small and Large Bowel Procedures with MCC: MS- DRG 329 • Major Chest Procedures without CC/MCC: MS-DRG 165 • Major Chest Procedures with MCC: MS-DRG 163 • Major Chest Procedures with CC: MS-DRG 164 • Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207 • Septicemia without Mechanical Ventilation 96+ Hours with MCC: MS-DRG 871 • Extensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981 • Extensive OR Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with CC - MS-DRG 988 • Coagulation Disorders: MS-DRG 813 • Peritoneal Adhesiolysis with MCC: MS-DRG 335 • Nonextensive Burns: MS-DRG 935 • Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674 • Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928 • OR Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876 • Infectious and Parasitic Diseases with OR Procedure without CC/MCC: MS-DRG 855 • Infectious and Parasitic Diseases with OR Procedure with CC: MS-DRG 854 • Postoperative or Posttraumatic Infections with OR Procedure without CC/MCC: MS-DRG 858 • Infectious and Parasitic Diseases with OR Procedure with MCC: MS-DRG 853 • Postoperative or Posttraumatic Infections with OR Procedure with CC: MS-DRG 857 • Postoperative or Posttraumatic Infections with OR Procedure with MCC: MS-DRG 856 • Wound Debridements for Injuries with CC: MS-DRG 902 • Wound Debridements for Injuries with MCC: MS-DRG 901 • Wound Debridements for Injuries without CC/MCC: MS-DRG 903 • Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673 • Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256 • Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC:















Hawaii Region D/HDI




For DMEMAC claims:• Urological bundling • Wheelchair Bundling • Knee Orthotic Bundling


• PEN supplies more than one time a day • Infusion Pump Denied/Accessories & Drug Codes should be denied • DMEPOS while patient is in a Covered Part A Inpatient Hospital Stay • SNF Consolidated Billing • A4221 Excessive Units • Prosthetic Bundling • DME while in Hospice • Medical Supplies and Home Health Consolidated billing • Date of Death-DME • Medically unlikely edits • DME duplicates • CPM device after three weeks





Idaho Region D/HDI

For Part A outpatient and Part B claims:• Neulasta (HCPCS code J2505) • Newborn Pediatric CPT Codes Billed for Patients Exceeding Age Limit


• Once in a Lifetime • Excessive Units—Untimed Codes • Excessive Units—Blood Transfusions • Excessive Units—Bronchoscopy • Excessive Units—IV Hydration • Global vs. TC/PC • Facility vs. Non-Facility Reimbursement (Inpatient) • SNF Consolidated Billing • Anesthesia Care Package E&M Services • NCCI Edits • Hospice Related Services – B • TC of Radiology • Not a New Patient - Providers are only allowed to bill the CPT codes for New Patient visits if the patient has




For non-medical necessity DRG-validation inpatient claims:• Amputations ( MS-DRGs 239-241, 255-257, 474-476, 616-618) • Blood & immunological procedures ( MS-DRGs 799, 800, 801, 802, 803, 804) • Burns ( MS-DRGs 927, 928, 929, 933, 934, 935) • Cardiac procedures ( MS-DRGs 034-036, 215, 222-227, 231-236, 242-249, 258-262, 265, 286-287) • Cardiovascular diseases ( MS-DRGs 280-285, 288-293, 296-311, 313-316) • Cardiovascular procedures ( MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 253, 254, 263, 264) • Blood & immunological disorders ( MS-DRGs 808, 809, 810, 811, 812, 813, 815, 815, 816) • Ear, nose, mouth & throat procedures ( MS-DRGs 129-139) • Endocrine, nutritional & metabolic disorders ( MS-DRGs 637-645) • Eye procedures ( MS-DRGs 113-117) • Female reproductive system procedures ( MS-DRGs 734-750) • Gastrointestinal disorders ( MS-DRGs 368-395 and 432-446) • Gastrointestinal procedures ( MS-DRGs 326-358, 405-415, 417-425) • Health status factors ( MS-DRGs 939, 940, 941, 945-951) • Infection ( MS-DRGs 094, 095, 096, 853, 854, 855, 867, 868, 869) • Kidney & urinary tract disorders ( MS-DRGs 682-690, 695-700) • Kidney & urinary tract procedures ( MS-DRGs 652-675 and 691, 692, 693, 694, 694) • Male reproductive system procedures ( MS-DRGs 707-718) • Malignant breast disorders (MS DRGs 597, 598, 599 ) • MDC 04 respiratory ( MS-DRGs 163-168, 175-208) • Mental diseases & disorders ( MS-DRGs 876, 880-887, 894-897) • Multiple significant trauma procedures ( MS-DRGs 955, 956, 957, 958, 959, 963, 964, 965) • Neoplasm ( MS-DRGs 837-849) • Neoplasm surgery ( MS-DRGs 837-849) • Nervous system disorders (MS-DRGS 052-074, 077-086, 088-093 and 097-103) • Nervous system procedures ( MS-DRGs 020-033 and 037-042) • OR procedure unrelated to principal diagnosis (MS DRGs 981 -989) • Postoperative or post-traumatic infection (MS DRGs 856, 857, 858, 862, 863 ) • Procedures for injuries ( MS-DRGs 907, 908, 909) • Septicemia ( MS-DRGs 870, 871, 872)


• Skin graft & connective tissue procedures ( MS-DRGs 463-465, 477-479, 500-502, 515-517, 573-581, 622-624, 901-905)

• Spinal fusion ( MS-DRGs 453, 454, 455, 456, 457, 458, 459, 460, 471, 472, 473, 490, 491) • Transplants ( MS-DRGs 001, 002, 003, 004, 005, 006, 007, 008, 009, 010, 011, 012, 013) • Pregnancy, Childbirth & Peruperium (MS-DRGs 765, 766, 767, 768, 769, 770, 771, 774, 775, 776, 777, 778,



Illinois Region B/CGI

For outpatient hospital and physician claims:• Blood Transfusions • IV-Hydration • Bronchoscopy Services • Neulasta • Once in a Lifetime Procedures • Untimed Codes • Intravenous Infusion Chemotherapy and Non-chemotherapy - Excessive Units Reported • PreAdmission Testing • Separately Paid Ambulance Service during Inpatient Hospitalization Review • Oxaliplatin

For DME claims:• Wheelchair Bundling

For inpatient hospital claims:• Hospital to Hospital Transfer

CSW Providers • CSW during Inpatient Hospital

For non-medical necessity DRG-validation inpatient claims

• Cardiac arrhythmia & conduction disorders w MCC or w CC DRG 138, MSDRG 308, 309

• Chronic Obstructive Pulmonary Disease DRG 88 MSDRG 190, 191

• Diseases and Disorders of the Respiratory System DRG 076,079 MSDRG166,167,177,178,179

• Esophagitis gastroenteritis and misc digest disorder w/MCC DRG 182 MSDRG 391

• Excisional Debridement MSDRG 463, 464, 465, 573, 574, 575, 901, 902, 903 (ICD9 86.22)

• Extensive OR procedure unrelated to Principal Diagnosis DRG 468 MSDRG 981,982,983

• Gastroenteritis Hemorrhage w/MCC wCC DRG 174,MS DRG 377,378,379

• Heart Failure & Shock w/MCC, w CC, w/o CC/MCC DRG 127 MS-DRG 291, 292, 293

• Intracaranial Hemorrhage or Cerebral Infarction DRG 014, MS-DRG 064, 065, 066

• Kidney & Urinary Tract Infections w/MCC DRG 320, MS-DRG 689

• Major joint replacement or reattachment w/MCC DRG 544 MS-DRG 469

• Nutritional & Metabolic Disorders w/MCC DRG 296, MS-DRG 640

• Renal Failure DRG 316, MS-DRG 682, 683, 684

• Respiratory system diagnosis w ventilator support DRG 475, 565,566 MS - DRG 207, 208

• Septicemia DRG 416, 576 MS-DRG 870, 871, 872

• Simple Pneumonia DRG 089, MSDRG 193, 194, 195

• Acute Respiratory Failure: MS-DRG 189


• Cardiac Defib Implant W Cardiac Cath W/O AMI/HF/Shock W MCC

• Cardiac Valve & Oth Maj Cardiothoracic Procedures w CC or MCC

• Carotid Artery Stent & Extracranial Procedures w CC or MCC

• Coronary Bypass W PTCA/Cardiac Cath w MCC

• Cranial/Facial Procedures w CC or MCC

• Craniotomy, Endovascular and Intracranial Vascular Procedures w CC or MCC

• Disorders Of The Eye, Infections And Procedures (Orbital And Interocular) w CC or MCC

• Major Cardiovasc Thoracic Aortic Aneurysm Repair Procedures w CC or MCC

• Major Chest Procedures w CC or MCC

• Major Head & Neck Procedures w CC or MCC

• Other Cardiothoracic Procedures w CC or MCC

• Other Ear, Nose, Mouth & Throat O.R.Procedures w CC or MCC

• Perc Cardiovasc Proc W Drug-Eluting Or Non Drug Eluting Stent w MCC or 4+ Vessels/Stents

• Periph/Cranial Nerve & Other Nerv Syst Proc w CC or MCC

• Tracheostomy MS-DRG Validation DRG 003, 004,011,012,013

• Ventricular Shunt Procedures W CC or MCC

• Spinal Procedures Neurostimulators

• Liver Transplant DRG 480 MSDRG 006

• Heart Transplant DRG 103 MSDRG 002

• Post Operative Anemia MSDRG 467, 481, 486, 488

• Cholecystectomy MS-DRGs 411-419

• Coronary bypass procedures MS-DRG 234, 236

• Craniotomy and endovascular intracranial procedures MS-DRG 027

• Hip and femur procedures MS-DRGs 495-499

• Major cardiovascular procedures MS-DRG 238

• Major joint procedures MS-DRGs 461, 462, 466, 468, 470

• Non-extensive O.R. procedure unrelated to principal diagnosis MS-DRGs 987- 989.

• Other OR procedures for injuries MS-DRGs 907- 909

• Pathological fractures MS-DRGs 542-544

• Spinal fusions MS-DRGs 453-460

• Urinary procedures MS-DRGs 653-675

• Soft tissue procedures MS-DRGs 500, 501, 502

• Seizures MS-DRGs 100, 101

• Obesity procedures MS-DRGs 619, 620, 621

• Human Immunodeficiency Virus (HIV) disease

• Metastasis as secondary MS-DRG 820-825, and 840- 842

• Lysis of adhesions MS-DRG 335-337, 350, and 351-355

• Cardiac valve and other major cardiothoracic procedures MS-DRGs 218, 221

• CAD versus unstable angina MS-DRG 311

Indiana Region B/CGI






• Major joint pr ocedures MS-DRGs 461, 462, 466, 468, 470













• CAD versus unstable angina MS-DRG 311 Iowa Region

D/HDIFor Part A outpatient and Part B claims:• Neulasta (HCPCS code J2505) • Newborn Pediatric CPT Codes Billed for Patients Exceeding Age Limit • Once in a Lifetime • Excessive Units—Untimed Codes • Excessive Units—Blood Transfusions • Excessive Units—Bronchoscopy • Excessive Units—IV Hydration • Global vs. TC/PC • Facility vs. Non-Facility Reimbursement (Inpatient) • SNF Consolidated Billing • Anesthesia Care Package E&M Services • NCCI Edits • Hospice Related Services – B • TC of Radiology • Not a New Patient - Providers are only allowed to bill the CPT codes for New Patient visits if the patient has




For non-medical necessity DRG-validation inpatient claims:• Amputations ( MS-DRGs 239-241, 255-257, 474-476, 616-618) • Blood & immunological procedures ( MS-DRGs 799, 800, 801, 802, 803, 804)


• Burns ( MS-DRGs 927, 928, 929, 933, 934, 935) • Cardiac procedures ( MS-DRGs 034-036, 215, 222-227, 231-236, 242-249, 258-262, 265, 286-287) • Cardiovascular diseases ( MS-DRGs 280-285, 288-293, 296-311, 313-316) • Cardiovascular procedures ( MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 253, 254, 263, 264) • Blood & immunological disorders ( MS-DRGs 808, 809, 810, 811, 812, 813, 815, 815, 816) • Ear, nose, mouth & throat procedures ( MS-DRGs 129-139) • Endocrine, nutritional & metabolic disorders ( MS-DRGs 637-645) • Eye procedures ( MS-DRGs 113-117) • Female reproductive system procedures ( MS-DRGs 734-750) • Gastrointestinal disorders ( MS-DRGs 368-395 and 432-446) • Gastrointestinal procedures ( MS-DRGs 326-358, 405-415, 417-425) • Health status factors ( MS-DRGs 939, 940, 941, 945-951) • Infection ( MS-DRGs 094, 095, 096, 853, 854, 855, 867, 868, 869) • Kidney & urinary tract disorders ( MS-DRGs 682-690, 695-700) • Kidney & urinary tract procedures ( MS-DRGs 652-675 and 691, 692, 693, 694, 694) • Male reproductive system procedures ( MS-DRGs 707-718) • Malignant breast disorders (MS DRGs 597, 598, 599 ) • MDC 04 respiratory ( MS-DRGs 163-168, 175-208) • Mental diseases & disorders ( MS-DRGs 876, 880-887, 894-897) • Multiple significant trauma procedures ( MS-DRGs 955, 956, 957, 958, 959, 963, 964, 965) • Neoplasm ( MS-DRGs 837-849) • Neoplasm surgery ( MS-DRGs 837-849) • Nervous system disorders (MS-DRGS 052-074, 077-086, 088-093 and 097-103) • Nervous system procedures ( MS-DRGs 020-033 and 037-042) • OR procedure unrelated to principal diagnosis (MS DRGs 981 -989) • Postoperative or post-traumatic infection (MS DRGs 856, 857, 858, 862, 863 ) • Procedures for injuries ( MS-DRGs 907, 908, 909) • Septicemia ( MS-DRGs 870, 871, 872) • Skin graft & connective tissue procedures ( MS-DRGs 463-465, 477-479, 500-502, 515-517, 573-581,




Kansas Region D/HDI



• OP services within 72 hours of admit


• Acute Hospital Readmissions without condition code B4 or 42 • Incorrect patient status-IRF • Medically unlikely edits (Part A Outpatient, Part B) • CSW During Inpatient





630)• Eye Disorders (MSDRGS 121-125) • Female Reproductive System Disorders (MSDRGS 754,-761) • HIV Infections (MSDRGS 969, 970, 974, 975, 976, 977) • Infection, Other (MSDRGS 075, 076, 864, 865, 866) • Joint Procedures (MSDRGS 461, 462, 466-470, 480-489, 492-494, 498, 499, 503-514, 535, 536, 906)


• Male Reproductive System Disorders (MSDRGS 754-761) • M usculoskeletal Disorders (MSDRGS 539, 540, 541, 545-558, 564, 565, 566) • Musculoskeletal Fractures (MSDRGS 495, 496, 497, 533, 534, 537, 538, 542, 543, 544, 562, 563) • Skin Disorders (MSDRGS 592, 593, 594, 595, 596, 602, 603, 604, 605, 606, 607) • Disorders Related to Injuries, Toxicity (MSDRGS 913, 914, 915, 916, 917, 918, 919, 920, 921, 922, 923)

Kentucky Region B/CGI






























































• CAD versus unstable angina MS-DRG 311 Louisiana Region

C/ Connolly




For non-medical necessity DRG validation reviews:• Peritoneal Adhesiolysis with MCC: MS-DRG 335 • Nonextensive Burns: MS-DRG 935 • Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674 • Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928 • OR Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876 • Infectious and Parasitic Diseases with OR Procedure without CC/MCC: MS-DRG 855 • Infectious and Parasitic Diseases with OR Procedure with CC: MS-DRG 854 • Postoperative or Posttraumatic Infections with OR Procedure without CC/MCC: MS-DRG 858 • Infectious and Parasitic Diseases with OR Procedure with MCC: MS-DRG 853 • Postoperative or Posttraumatic Infections with OR Procedure with CC: MS-DRG 857 • Postoperative or Posttraumatic Infections with OR Procedure with MCC: MS-DRG 856 • Wound Debridements for Injuries with CC: MS-DRG 902


• Wound Debridements for Injuries with MCC: MS-DRG 901 • Wound Debridements for Injuries without CC/MCC: MS-DRG 903 • Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673 • Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256 • Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC:











246• Other vascular procedures with CC: MS-DRG 253 • Other female reproductive system O.R. procedures with CC/MCC: MS-DRG 749 • Other O.R. procedures of the blood and blood-forming organs with CC: MS-DRG 803 • Lymphoma and nonacute leukemia with other O.R. procedure with MCC: MS-DRG 823 • Other circulatory system diagnoses with CC: MS-DRG 315 • Amputation of lower limb for endocrine, nutritional, and metabolic dsorders with CC: MS-DRG 617


• Myeloproliferative disorders or poorly differentiated neoplasms with other O.R. procedure with CC/MCC: MS- DRG 829

• Knee procedures with principal diagnosis of infection with CC: MS-DRG 486 • O.R. procedure with diagnoses of other contact with health services without CC/MCC: MS-DRG 941 • Skin graft and/or debridement except for skin ulcer or cellulitis with CC: MS-DRG 577 • Other digestive system O.R. procedures without CC/MCC: MS-DRG 358 • Other ear, nose, mouth and throat O.R. procedures with CC/MCC: MS-DRG 133 • Other hepatobiliary or pancreas O.R. procedures with CC: MS-DRG 424 • Amputation of lower limb for endocrine, nutritional, and metabolic disorders with MCC: MS-DRG 616 • Other kidney and urinary tract procedures without CC/MCC: MS-DRG 675 • Other male reproductive system O.R. procedures except malignancy with CC/MCC: MS-DRG 717 .• Peripheral/cranial nerve and other nervous system procedures with CC or peripheral neurostimulator: MS-


Maine Region A/DCS










• MS-DRG validation for intracranial hemorrhage or cerebral infarction Maryland Region


Massachusetts Region A/DCS

For DME supplier claims:• Pharmacy Supply and Dispensing Fees • Wheelchair Bundling • Urological Bundling • Wheel Attachment with New Non-Wheeled Walker • Headrest with a Power Operated Vehicle or a Power Wheelchair with a Captain's Chair Seat • Multiple DME Rentals within a Month • Prosthetic Additions with Initial or Preparatory Knee Prosthesis


• Lower Limb Suction Value Prosthesis • Solid Insert with Seat or Back Wheelchair Cushions • Oxygen Accessories









• MS-DRG validation for intracranial hemorrhage or cerebral infarction Michigan Region

B/CGIFor outpatient hospital and physician claims:• Blood Transfusions • IV-Hydration • Bronchoscopy Services • Neulasta • Once in a Lifetime Procedures • Untimed Codes • Intravenous Infusion Chemotherapy and Non-chemotherapy - Excessive Units Reported • PreAdmission Testing • Separately Paid Ambulance Service during Inpatient Hospitalization Review • Oxaliplatin





























































• CAD versus unstable angina MS-DRG 311 Minnesota Region

B/CGIFor outpatient hospital and physician claims:• Blood Transfusions • IV-Hydration • Bronchoscopy Services • Neulasta • Once in a Lifetime Procedures • Untimed Codes • Intravenous Infusion Chemotherapy and Non-chemotherapy - Excessive Units Reported • PreAdmission Testing


• Separately Paid Ambulance Service during Inpatient Hospitalization Review • Oxaliplatin






























































Mississippi Region C/ Connolly




For non-medical necessity DRG validation reviews:• Peritoneal Adhesiolysis with MCC: MS-DRG 335 • Nonextensive Burns: MS-DRG 935 • Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674 • Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928 • OR Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876 • Infectious and Parasitic Diseases with OR Procedure without CC/MCC: MS-DRG 855 • Infectious and Parasitic Diseases with OR Procedure with CC: MS-DRG 854 • Postoperative or Posttraumatic Infections with OR Procedure without CC/MCC: MS-DRG 858 • Infectious and Parasitic Diseases with OR Procedure with MCC: MS-DRG 853 • Postoperative or Posttraumatic Infections with OR Procedure with CC: MS-DRG 857 • Postoperative or Posttraumatic Infections with OR Procedure with MCC: MS-DRG 856 • Wound Debridements for Injuries with CC: MS-DRG 902 • Wound Debridements for Injuries with MCC: MS-DRG 901 • Wound Debridements for Injuries without CC/MCC: MS-DRG 903 • Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673 • Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256 • Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC:


DRG 463


• Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with CC: MS- DRG 464

• Skin Graft and/or Debridement for Skin Ulcer or Cellulitis without CC/MCC: MS-DRG 575 • Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with MCC: MS-DRG 576 • Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis without CC/MCC: MS-DRG 578 • Other Hepatobiliary or Pancreas OR Procedures with MCC: MS-DRG 423 • Other Digestive System OR Procedures with CC: MS-DRG 357 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with MCC: MS-DRG










DRG 041


• Major bladder procedures with CC: MS-DRG 654 • Stomach, esophageal and duodenal procedures with CC: MS-DRG 327 • Rectal resection with CC: MS-DRG 333 • Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with CC: MS-DRG 217

Missouri Region D/HDI





For non-medical necessity DRG-validation inpatient claims:• Amputations ( MS-DRGs 239-241, 255-257, 474-476, 616-618) • Blood & immunological procedures ( MS-DRGs 799, 800, 801, 802, 803, 804) • Burns ( MS-DRGs 927, 928, 929, 933, 934, 935) • Cardiac procedures ( MS-DRGs 034-036, 215, 222-227, 231-236, 242-249, 258-262, 265, 286-287) • Cardiovascular diseases ( MS-DRGs 280-285, 288-293, 296-311, 313-316) • Cardiovascular procedures ( MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 253, 254, 263, 264) • Blood & immunological disorders ( MS-DRGs 808, 809, 810, 811, 812, 813, 815, 815, 816) • Ear, nose, mouth & throat procedures ( MS-DRGs 129-139) • Endocrine, nutritional & metabolic disorders ( MS-DRGs 637-645) • Eye procedures ( MS-DRGs 113-117) • Female reproductive system procedures ( MS-DRGs 734-750) • Gastrointestinal disorders ( MS-DRGs 368-395 and 432-446) • Gastrointestinal procedures ( MS-DRGs 326-358, 405-415, 417-425) • Health status factors ( MS-DRGs 939, 940, 941, 945-951) • Infection ( MS-DRGs 094, 095, 096, 853, 854, 855, 867, 868, 869) • Kidney & urinary tract disorders ( MS-DRGs 682-690, 695-700) • Kidney & urinary tract procedures ( MS-DRGs 652-675 and 691, 692, 693, 694, 694) • Male reproductive system procedures ( MS-DRGs 707-718) • Malignant breast disorders (MS DRGs 597, 598, 599 ) • MDC 04 respiratory ( MS-DRGs 163-168, 175-208) • Mental diseases & disorders ( MS-DRGs 876, 880-887, 894-897) • Multiple significant trauma procedures ( MS-DRGs 955, 956, 957, 958, 959, 963, 964, 965) • Neoplasm ( MS-DRGs 837-849)


• Neoplasm surgery ( MS-DRGs 837-849) • Nervous system disorders (MS-DRGS 052-074, 077-086, 088-093 and 097-103) • Nervous system procedures ( MS-DRGs 020-033 and 037-042) • OR procedure unrelated to principal diagnosis (MS DRGs 981 -989) • Postoperative or post-traumatic infection (MS DRGs 856, 857, 858, 862, 863 ) • Procedures for injuries ( MS-DRGs 907, 908, 909) • Septicemia ( MS-DRGs 870, 871, 872) • Skin graft & connective tissue procedures ( MS-DRGs 463-465, 477-479, 500-502, 515-517, 573-581,




Montana Region D/HDI










Nebraska Region D/HDI

For Part A outpatient and Part B claims:• Neulasta (HCPCS code J2505) • Newborn Pediatric CPT Codes Billed for Patients Exceeding Age Limit • Once in a Lifetime • Excessive Units—Untimed Codes • Excessive Units—Blood Transfusions • Excessive Units—Bronchoscopy • Excessive Units—IV Hydration • Global vs. TC/PC • Facility vs. Non-Facility Reimbursement (Inpatient) • SNF Consolidated Billing • Anesthesia Care Package E&M Services • NCCI Edits • Hospice Related Services – B • TC of Radiology


• Not a New Patient - Providers are only allowed to bill the CPT codes for New Patient visits if the patient has not received any professional services from the physician or physician group practice within the previous 3 years.






630)• Eye Disorders (MSDRGS 121-125)


• Female Reproductive System Disorders (MSDRGS 754,-761) • HIV Infections (MSDRGS 969, 970, 974, 975, 976, 977) • Infection, Other (MSDRGS 075, 076, 864, 865, 866) • Joint Procedures (MSDRGS 461, 462, 466-470, 480-489, 492-494, 498, 499, 503-514, 535, 536, 906) • Male Reproductive System Disorders (MSDRGS 754-761) • M usculoskeletal Disorders (MSDRGS 539, 540, 541, 545-558, 564, 565, 566) • Musculoskeletal Fractures (MSDRGS 495, 496, 497, 533, 534, 537, 538, 542, 543, 544, 562, 563) • Skin Disorders (MSDRGS 592, 593, 594, 595, 596, 602, 603, 604, 605, 606, 607) • Disorders Related to Injuries, Toxicity (MSDRGS 913, 914, 915, 916, 917, 918, 919, 920, 921, 922, 923)

Nevada Region D/HDI





For non-medical necessity DRG-validation inpatient claims:• Amputations ( MS-DRGs 239-241, 255-257, 474-476, 616-618) • Blood & immunological procedures ( MS-DRGs 799, 800, 801, 802, 803, 804) • Burns ( MS-DRGs 927, 928, 929, 933, 934, 935) • Cardiac procedures ( MS-DRGs 034-036, 215, 222-227, 231-236, 242-249, 258-262, 265, 286-287) • Cardiovascular diseases ( MS-DRGs 280-285, 288-293, 296-311, 313-316) • Cardiovascular procedures ( MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 253, 254, 263, 264) • Blood & immunological disorders ( MS-DRGs 808, 809, 810, 811, 812, 813, 815, 815, 816) • Ear, nose, mouth & throat procedures ( MS-DRGs 129-139) • Endocrine, nutritional & metabolic disorders ( MS-DRGs 637-645) • Eye procedures ( MS-DRGs 113-117) • Female reproductive system procedures ( MS-DRGs 734-750) • Gastrointestinal disorders ( MS-DRGs 368-395 and 432-446) • Gastrointestinal procedures ( MS-DRGs 326-358, 405-415, 417-425) • Health status factors ( MS-DRGs 939, 940, 941, 945-951) • Infection ( MS-DRGs 094, 095, 096, 853, 854, 855, 867, 868, 869) • Kidney & urinary tract disorders ( MS-DRGs 682-690, 695-700) • Kidney & urinary tract procedures ( MS-DRGs 652-675 and 691, 692, 693, 694, 694)


• Male reproductive system procedures ( MS-DRGs 707-718) • Malignant breast disorders (MS DRGs 597, 598, 599 ) • MDC 04 respiratory ( MS-DRGs 163-168, 175-208) • Mental diseases & disorders ( MS-DRGs 876, 880-887, 894-897) • Multiple significant trauma procedures ( MS-DRGs 955, 956, 957, 958, 959, 963, 964, 965) • Neoplasm ( MS-DRGs 837-849) • Neoplasm surgery ( MS-DRGs 837-849) • Nervous system disorders (MS-DRGS 052-074, 077-086, 088-093 and 097-103) • Nervous system procedures ( MS-DRGs 020-033 and 037-042) • OR procedure unrelated to principal diagnosis (MS DRGs 981 -989) • Postoperative or post-traumatic infection (MS DRGs 856, 857, 858, 862, 863 ) • Procedures for injuries ( MS-DRGs 907, 908, 909) • Septicemia ( MS-DRGs 870, 871, 872) • Skin graft & connective tissue procedures ( MS-DRGs 463-465, 477-479, 500-502, 515-517, 573-581,




New Hampshire

Region A/DCS










• MS-DRG validation for intracranial hemorrhage or cerebral infarction New Jersey Region

A/DCSFor DME supplier claims:• Pharmacy Supply and Dispensing Fees


• Wheelchair Bundling • Urological Bundling • Wheel Attachment with New Non-Wheeled Walker • Headrest with a Power Operated Vehicle or a Power Wheelchair with a Captain's Chair Seat • Multiple DME Rentals within a Month • Prosthetic Additions with Initial or Preparatory Knee Prosthesis • Lower Limb Suction Value Prosthesis • Solid Insert with Seat or Back Wheelchair Cushions • Oxygen Accessories








• MS-DRG validation for intracranial hemorrhage or cerebral infarction New Mexico Region

C/ Connolly



For non-medical necessity DRG validation reviews:• Upper Limb and Toe Amputation for Circulatory System Disorders with MCC: MS-DRG 255 • Cirrhosis and Alcoholic Hepatitis with MCC: MS- DRG 432 • Septicemia without Mechanical Ventilation 96+ Hours without MCC: MS-DRG 872 • Nonextensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC - MS-DRG 989 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987 • Other Respiratory System OR Procedures without CC/MCC: MS-DRG 168 • Extensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983 • Other Respiratory System OR Procedures with CC: MS-DRG 167 • Other Digestive System Diagnoses with CC: MS-DRG 394 • Inflammatory Bowel Disease with CC: MS-DRG 386 • Major Gastrointestinal Disorders and Peritoneal Infections without CC/MCC: MS-DRG 372 • Other Respiratory System OR Procedures with MCC: MS-DRG 166 • Major Small and Large Bowel Procedures without CC/MCC: MS-DRG 331 • Major Small and Large Bowel Procedures with CC: MS-DRG 330 • Major Small and Large Bowel Procedures with MCC: MS- DRG 329 • Major Chest Procedures without CC/MCC: MS-DRG 165 • Major Chest Procedures with MCC: MS-DRG 163 • Major Chest Procedures with CC: MS-DRG 164 • Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207 • Septicemia without Mechanical Ventilation 96+ Hours with MCC: MS-DRG 871 • Extensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981 • Extensive OR Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with CC - MS-DRG 988 • Coagulation Disorders: MS-DRG 813 • Peritoneal Adhesiolysis with MCC: MS-DRG 335 • Nonextensive Burns: MS-DRG 935 • Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674 • Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928 • OR Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876 • Infectious and Parasitic Diseases with OR Procedure without CC/MCC: MS-DRG 855 • Infectious and Parasitic Diseases with OR Procedure with CC: MS-DRG 854 • Postoperative or Posttraumatic Infections with OR Procedure without CC/MCC: MS-DRG 858


• Infectious and Parasitic Diseases with OR Procedure with MCC: MS-DRG 853 • Postoperative or Posttraumatic Infections with OR Procedure with CC: MS-DRG 857 • Postoperative or Posttraumatic Infections with OR Procedure with MCC: MS-DRG 856 • Wound Debridements for Injuries with CC: MS-DRG 902 • Wound Debridements for Injuries with MCC: MS-DRG 901 • Wound Debridements for Injuries without CC/MCC: MS-DRG 903 • Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673 • Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256 • Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC:











246• Other vascular procedures with CC: MS-DRG 253 • Other female reproductive system O.R. procedures with CC/MCC: MS-DRG 749


• Other O.R. procedures of the blood and blood-forming organs with CC: MS-DRG 803 • Lymphoma and nonacute leukemia with other O.R. procedure with MCC: MS-DRG 823 • Other circulatory system diagnoses with CC: MS-DRG 315 • Amputation of lower limb for endocrine, nutritional, and metabolic dsorders with CC: MS-DRG 617 • Myeloproliferative disorders or poorly differentiated neoplasms with other O.R. procedure with CC/MCC: MS-



For outpatient hospital and physician claims:• Once in a lifetime procedures • J2505: Injection, Pegfilgrastim, 6 mg • Medically Unlikely Edit List • Nebulizer, Demonstration and Evaluation Units Billed • Adenosine - Dose vs. Units billed • Barium Swallow Studies Units Billed

New York Region A/DCS









• MS-DRG validation for intracranial hemorrhage or cerebral infarction North Carolina Region

C/ Connolly



For outpatient hospital and physician claims:


• Untimed codes • Once in a lifetime procedures • Pediatric codes exceeding age parameters • J2505: Injection, Pegfilgrastim, 6 mg • Medically Unlikely Edit List • Nebulizer, Demonstration and Evaluation Units Billed • Adenosine - Dose vs. Units billed • Barium Swallow Studies Units Billed

For non-medical necessity DRG validation reviews:• Upper Limb and Toe Amputation for Circulatory System Disorders with MCC: MS-DRG 255 • Cirrhosis and Alcoholic Hepatitis with MCC: MS- DRG 432 • Septicemia without Mechanical Ventilation 96+ Hours without MCC: MS-DRG 872 • Nonextensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC - MS-DRG 989 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987 • Other Respiratory System OR Procedures without CC/MCC: MS-DRG 168 • Extensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983 • Other Respiratory System OR Procedures with CC: MS-DRG 167 • Other Digestive System Diagnoses with CC: MS-DRG 394 • Inflammatory Bowel Disease with CC: MS-DRG 386 • Major Gastrointestinal Disorders and Peritoneal Infections without CC/MCC: MS-DRG 372 • Other Respiratory System OR Procedures with MCC: MS-DRG 166 • Major Small and Large Bowel Procedures without CC/MCC: MS-DRG 331 • Major Small and Large Bowel Procedures with CC: MS-DRG 330 • Major Small and Large Bowel Procedures with MCC: MS- DRG 329 • Major Chest Procedures without CC/MCC: MS-DRG 165 • Major Chest Procedures with MCC: MS-DRG 163 • Major Chest Procedures with CC: MS-DRG 164 • Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207 • Septicemia without Mechanical Ventilation 96+ Hours with MCC: MS-DRG 871 • Extensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981 • Extensive OR Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with CC - MS-DRG 988 • Coagulation Disorders: MS-DRG 813 • Peritoneal Adhesiolysis with MCC: MS-DRG 335 • Nonextensive Burns: MS-DRG 935 • Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674 • Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928 • OR Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876 • Infectious and Parasitic Diseases with OR Procedure without CC/MCC: MS-DRG 855 • Infectious and Parasitic Diseases with OR Procedure with CC: MS-DRG 854 • Postoperative or Posttraumatic Infections with OR Procedure without CC/MCC: MS-DRG 858 • Infectious and Parasitic Diseases with OR Procedure with MCC: MS-DRG 853 • Postoperative or Posttraumatic Infections with OR Procedure with CC: MS-DRG 857 • Postoperative or Posttraumatic Infections with OR Procedure with MCC: MS-DRG 856 • Wound Debridements for Injuries with CC: MS-DRG 902 • Wound Debridements for Injuries with MCC: MS-DRG 901 • Wound Debridements for Injuries without CC/MCC: MS-DRG 903 • Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673 • Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256 • Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC:















North Dakota Region D/HDI

For Part A outpatient and Part B claims:• Neulasta (HCPCS code J2505) • Newborn Pediatric CPT Codes Billed for Patients Exceeding Age Limit • Once in a Lifetime • Excessive Units—Untimed Codes • Excessive Units—Blood Transfusions


• Excessive Units—Bronchoscopy • Excessive Units—IV Hydration • Global vs. TC/PC • Facility vs. Non-Facility Reimbursement (Inpatient) • SNF Consolidated Billing • Anesthesia Care Package E&M Services • NCCI Edits • Hospice Related Services – B • TC of Radiology • Not a New Patient - Providers are only allowed to bill the CPT codes for New Patient visits if the patient has





622-624, 901-905)• Spinal fusion ( MS-DRGs 453, 454, 455, 456, 457, 458, 459, 460, 471, 472, 473, 490, 491)


• Transplants ( MS-DRGs 001, 002, 003, 004, 005, 006, 007, 008, 009, 010, 011, 012, 013) • Pregnancy, Childbirth & Peruperium (MS-DRGs 765, 766, 767, 768, 769, 770, 771, 774, 775, 776, 777, 778,



Ohio Region B/CGI































































Oklahoma Region C/ Connolly



For non-medical necessity DRG validation reviews:• Upper Limb and Toe Amputation for Circulatory System Disorders with MCC: MS-DRG 255 • Cirrhosis and Alcoholic Hepatitis with MCC: MS- DRG 432 • Septicemia without Mechanical Ventilation 96+ Hours without MCC: MS-DRG 872 • Nonextensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC - MS-DRG 989


• Nonextensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987 • Other Respiratory System OR Procedures without CC/MCC: MS-DRG 168 • Extensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983 • Other Respiratory System OR Procedures with CC: MS-DRG 167 • Other Digestive System Diagnoses with CC: MS-DRG 394 • Inflammatory Bowel Disease with CC: MS-DRG 386 • Major Gastrointestinal Disorders and Peritoneal Infections without CC/MCC: MS-DRG 372 • Other Respiratory System OR Procedures with MCC: MS-DRG 166 • Major Small and Large Bowel Procedures without CC/MCC: MS-DRG 331 • Major Small and Large Bowel Procedures with CC: MS-DRG 330 • Major Small and Large Bowel Procedures with MCC: MS- DRG 329 • Major Chest Procedures without CC/MCC: MS-DRG 165 • Major Chest Procedures with MCC: MS-DRG 163 • Major Chest Procedures with CC: MS-DRG 164 • Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207 • Septicemia without Mechanical Ventilation 96+ Hours with MCC: MS-DRG 871 • Extensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981 • Extensive OR Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with CC - MS-DRG 988 • Coagulation Disorders: MS-DRG 813 • Peritoneal Adhesiolysis with MCC: MS-DRG 335 • Nonextensive Burns: MS-DRG 935 • Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674 • Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928 • OR Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876 • Infectious and Parasitic Diseases with OR Procedure without CC/MCC: MS-DRG 855 • Infectious and Parasitic Diseases with OR Procedure with CC: MS-DRG 854 • Postoperative or Posttraumatic Infections with OR Procedure without CC/MCC: MS-DRG 858 • Infectious and Parasitic Diseases with OR Procedure with MCC: MS-DRG 853 • Postoperative or Posttraumatic Infections with OR Procedure with CC: MS-DRG 857 • Postoperative or Posttraumatic Infections with OR Procedure with MCC: MS-DRG 856 • Wound Debridements for Injuries with CC: MS-DRG 902 • Wound Debridements for Injuries with MCC: MS-DRG 901 • Wound Debridements for Injuries without CC/MCC: MS-DRG 903 • Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673 • Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256 • Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC:






CC/MCC: MS-DRG 465 • Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with MCC: MS-DRG 573 • Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC: MS-DRG 574 • Other Vascular Procedures with MCC: MS-DRG 252 • Respiratory system diagnosis with ventilator support < 96 Hours: MS-DRG 208 • Extracranial procedures with CC: MS-DRG 038 • Cardiac defibrillator implant without cardiac catheterization without MCC: MS-DRG 227 • Amputation for circulatory system disorders except upper limb and toe with CC: MS-DRG 240 • Permanent cardiac pacemaker implant with MCC: MS-DRG 242 • Other O.R. procedures for multiple significant trauma with MCC: MS-DRG 957 • Minor small and large bowel procedures with MCC: MS-DRG 344


• Knee procedures without principal diagnosis of infection with CC/MCC: MS-DRG 488 • Fractures of femur with MCC: MS-DRG 533 • Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with MCC: MS-DRG








For outpatient hospital and physician claims:• Once in a lifetime procedures • J2505: Injection, Pegfilgrastim, 6 mg • Medically Unlikely Edit List • Nebulizer, Demonstration and Evaluation Units Billed • Adenosine - Dose vs. Units billed • Barium Swallow Studies Units Billed

Oregon Region D/HDI

For Part A outpatient and Part B claims:• Neulasta (HCPCS code J2505) • Newborn Pediatric CPT Codes Billed for Patients Exceeding Age Limit • Once in a Lifetime • Excessive Units—Untimed Codes • Excessive Units—Blood Transfusions • Excessive Units—Bronchoscopy • Excessive Units—IV Hydration • Global vs. TC/PC • Facility vs. Non-Facility Reimbursement (Inpatient) • SNF Consolidated Billing


• Anesthesia Care Package E&M Services • NCCI Edits • Hospice Related Services – B • TC of Radiology • Not a New Patient - Providers are only allowed to bill the CPT codes for New Patient visits if the patient has


• OP services within 72 hours of admit • Acute Hospital Readmissions without condition code B4 or 42 • Incorrect patient status-IRF • Medically unlikely edits (Part A Outpatient, Part B) • CSW During Inpatient • DME duplicates • CPM device after three weeks

For DMEMAC claims:• Urological bundling • Wheelchair Bundling • Knee Orthotic Bundling • PEN supplies more than one time a day • Infusion Pump Denied/Accessories & Drug Codes should be denied • DMEPOS while patient is in a Covered Part A Inpatient Hospital Stay • SNF Consolidated Billing • A4221 Excessive Units • Prosthetic Bundling • DME while in Hospice • Medical Supplies and Home Health Consolidated billing • Date of Death-DME • Medically unlikely edits



779, 780, 781, 782• Breast Procedures (MSDRGS 582, 583, 584, 585, 600, 601) • Cardiovascular, Other (MSDRGS 294, 295, 312)


• Ear, Nose, Mouth & Throat Disorders (MSDRGS 146-159) • Endocrine, Nutritional & Metabolic Procedures (MSDRGS 614, 615, 619, 620, 621, 625, 626, 627, 628, 629,


Pennsylvania Region A/DCS









• MS-DRG validation for intracranial hemorrhage or cerebral infarction Rhode Island Region







• MS-DRG Validation for MS-DRGs for Tracheostomy (At this time, Medical Necessity is excluded from


review.)



• MS-DRG validation for intracranial hemorrhage or cerebral infarction South Carolina Region

C/ Connolly



For outpatient hospital and physician claims:• Blood transfusions • Untimed codes • IV hydration therapy • Bronchoscopy services • Once-in-a-lifetime procedures • Pediatric codes exceeding age parameters. • J2505 (Injection, Pegfilgrastim, 6 mg) • Medically Unlikely Edit List • Nebulizer, Demonstration and Evaluation Units Billed • Adenosine - Dose vs. Units billed • Barium Swallow Studies Units Billed

For non-medical necessity DRG validation reviews:• Upper Limb and Toe Amputation for Circulatory System Disorders with MCC: MS-DRG 255 • Cirrhosis and Alcoholic Hepatitis with MCC: MS- DRG 432 • Septicemia without Mechanical Ventilation 96+ Hours without MCC: MS-DRG 872 • Nonextensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC - MS-DRG 989 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987 • Other Respiratory System OR Procedures without CC/MCC: MS-DRG 168 • Extensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983 • Other Respiratory System OR Procedures with CC: MS-DRG 167 • Other Digestive System Diagnoses with CC: MS-DRG 394 • Inflammatory Bowel Disease with CC: MS-DRG 386 • Major Gastrointestinal Disorders and Peritoneal Infections without CC/MCC: MS-DRG 372 • Other Respiratory System OR Procedures with MCC: MS-DRG 166 • Major Small and Large Bowel Procedures without CC/MCC: MS-DRG 331 • Major Small and Large Bowel Procedures with CC: MS-DRG 330 • Major Small and Large Bowel Procedures with MCC: MS- DRG 329 • Major Chest Procedures without CC/MCC: MS-DRG 165 • Major Chest Procedures with MCC: MS-DRG 163 • Major Chest Procedures with CC: MS-DRG 164 • Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207 • Septicemia without Mechanical Ventilation 96+ Hours with MCC: MS-DRG 871 • Extensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981 • Extensive OR Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with CC - MS-DRG 988 • Coagulation Disorders: MS-DRG 813 • Peritoneal Adhesiolysis with MCC: MS-DRG 335 • Nonextensive Burns: MS-DRG 935 • Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674 • Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928 • OR Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876 • Infectious and Parasitic Diseases with OR Procedure without CC/MCC: MS-DRG 855 • Infectious and Parasitic Diseases with OR Procedure with CC: MS-DRG 854 • Postoperative or Posttraumatic Infections with OR Procedure without CC/MCC: MS-DRG 858 • Infectious and Parasitic Diseases with OR Procedure with MCC: MS-DRG 853 • Postoperative or Posttraumatic Infections with OR Procedure with CC: MS-DRG 857 • Postoperative or Posttraumatic Infections with OR Procedure with MCC: MS-DRG 856 • Wound Debridements for Injuries with CC: MS-DRG 902 • Wound Debridements for Injuries with MCC: MS-DRG 901 • Wound Debridements for Injuries without CC/MCC: MS-DRG 903 • Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673


• Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256 • Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC:












DRG 829• Knee procedures with principal diagnosis of infection with CC: MS-DRG 486


• O.R. procedure with diagnoses of other contact with health services without CC/MCC: MS-DRG 941 • Skin graft and/or debridement except for skin ulcer or cellulitis with CC: MS-DRG 577 • Other digestive system O.R. procedures without CC/MCC: MS-DRG 358 • Other ear, nose, mouth and throat O.R. procedures with CC/MCC: MS-DRG 133 • Other hepatobiliary or pancreas O.R. procedures with CC: MS-DRG 424 • Amputation of lower limb for endocrine, nutritional, and metabolic disorders with MCC: MS-DRG 616 • Other kidney and urinary tract procedures without CC/MCC: MS-DRG 675 • Other male reproductive system O.R. procedures except malignancy with CC/MCC: MS-DRG 717 .• Peripheral/cranial nerve and other nervous system procedures with CC or peripheral neurostimulator: MS-


South Dakota Region D/HDI



• OP services within 72 hours of admit • Acute Hospital Readmissions without condition code B4 or 42 • Incorrect patient status-IRF • Medically unlikely edits (Part A Outpatient, Part B) • CSW During Inpatient • DME duplicates • CPM device after three weeks

For DMEMAC claims:• Urological bundling • Wheelchair Bundling • Knee Orthotic Bundling • PEN supplies more than one time a day • Infusion Pump Denied/Accessories & Drug Codes should be denied • DMEPOS while patient is in a Covered Part A Inpatient Hospital Stay • SNF Consolidated Billing • A4221 Excessive Units • Prosthetic Bundling • DME while in Hospice • Medical Supplies and Home Health Consolidated billing • Date of Death-DME • Medically unlikely edits

For non-medical necessity DRG-validation inpatient claims:• Amputations ( MS-DRGs 239-241, 255-257, 474-476, 616-618) • Blood & immunological procedures ( MS-DRGs 799, 800, 801, 802, 803, 804) • Burns ( MS-DRGs 927, 928, 929, 933, 934, 935) • Cardiac procedures ( MS-DRGs 034-036, 215, 222-227, 231-236, 242-249, 258-262, 265, 286-287) • Cardiovascular diseases ( MS-DRGs 280-285, 288-293, 296-311, 313-316) • Cardiovascular procedures ( MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 253, 254, 263, 264) • Blood & immunological disorders ( MS-DRGs 808, 809, 810, 811, 812, 813, 815, 815, 816) • Ear, nose, mouth & throat procedures ( MS-DRGs 129-139) • Endocrine, nutritional & metabolic disorders ( MS-DRGs 637-645) • Eye procedures ( MS-DRGs 113-117) • Female reproductive system procedures ( MS-DRGs 734-750) • Gastrointestinal disorders ( MS-DRGs 368-395 and 432-446) • Gastrointestinal procedures ( MS-DRGs 326-358, 405-415, 417-425)


• Health status factors ( MS-DRGs 939, 940, 941, 945-951) • Infection ( MS-DRGs 094, 095, 096, 853, 854, 855, 867, 868, 869) • Kidney & urinary tract disorders ( MS-DRGs 682-690, 695-700) • Kidney & urinary tract procedures ( MS-DRGs 652-675 and 691, 692, 693, 694, 694) • Male reproductive system procedures ( MS-DRGs 707-718) • Malignant breast disorders (MS DRGs 597, 598, 599 ) • MDC 04 respiratory ( MS-DRGs 163-168, 175-208) • Mental diseases & disorders ( MS-DRGs 876, 880-887, 894-897) • Multiple significant trauma procedures ( MS-DRGs 955, 956, 957, 958, 959, 963, 964, 965) • Neoplasm ( MS-DRGs 837-849) • Neoplasm surgery ( MS-DRGs 837-849) • Nervous system disorders (MS-DRGS 052-074, 077-086, 088-093 and 097-103) • Nervous system procedures ( MS-DRGs 020-033 and 037-042) • OR procedure unrelated to principal diagnosis (MS DRGs 981 -989) • Postoperative or post-traumatic infection (MS DRGs 856, 857, 858, 862, 863 ) • Procedures for injuries ( MS-DRGs 907, 908, 909) • Septicemia ( MS-DRGs 870, 871, 872) • Skin graft & connective tissue procedures ( MS-DRGs 463-465, 477-479, 500-502, 515-517, 573-581,




Tennessee Region C/ Connolly



For non-medical necessity DRG validation reviews:• Upper Limb and Toe Amputation for Circulatory System Disorders with MCC: MS-DRG 255 • Cirrhosis and Alcoholic Hepatitis with MCC: MS- DRG 432 • Septicemia without Mechanical Ventilation 96+ Hours without MCC: MS-DRG 872 • Nonextensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC - MS-DRG 989 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987 • Other Respiratory System OR Procedures without CC/MCC: MS-DRG 168 • Extensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983 • Other Respiratory System OR Procedures with CC: MS-DRG 167 • Other Digestive System Diagnoses with CC: MS-DRG 394 • Inflammatory Bowel Disease with CC: MS-DRG 386 • Major Gastrointestinal Disorders and Peritoneal Infections without CC/MCC: MS-DRG 372 • Other Respiratory System OR Procedures with MCC: MS-DRG 166 • Major Small and Large Bowel Procedures without CC/MCC: MS-DRG 331 • Major Small and Large Bowel Procedures with CC: MS-DRG 330 • Major Small and Large Bowel Procedures with MCC: MS- DRG 329 • Major Chest Procedures without CC/MCC: MS-DRG 165 • Major Chest Procedures with MCC: MS-DRG 163 • Major Chest Procedures with CC: MS-DRG 164 • Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207 • Septicemia without Mechanical Ventilation 96+ Hours with MCC: MS-DRG 871


• Extensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981 • Extensive OR Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with CC - MS-DRG 988 • Coagulation Disorders: MS-DRG 813 • Peritoneal Adhesiolysis with MCC: MS-DRG 335 • Nonextensive Burns: MS-DRG 935 • Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674 • Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928 • OR Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876 • Infectious and Parasitic Diseases with OR Procedure without CC/MCC: MS-DRG 855 • Infectious and Parasitic Diseases with OR Procedure with CC: MS-DRG 854 • Postoperative or Posttraumatic Infections with OR Procedure without CC/MCC: MS-DRG 858 • Infectious and Parasitic Diseases with OR Procedure with MCC: MS-DRG 853 • Postoperative or Posttraumatic Infections with OR Procedure with CC: MS-DRG 857 • Postoperative or Posttraumatic Infections with OR Procedure with MCC: MS-DRG 856 • Wound Debridements for Injuries with CC: MS-DRG 902 • Wound Debridements for Injuries with MCC: MS-DRG 901 • Wound Debridements for Injuries without CC/MCC: MS-DRG 903 • Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673 • Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256 • Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC:









with MCC: MS-DRG 222• Pneumothorax without CC/MCC: MS-DRG 201 • Rehabilitation with CC/MCC: MS-DRG 945 • Major joint replacement or reattachment of lower extremity without MCC: MS-DRG 470 • Psychoses: MS-DRG 885 • Heart failure and shock with MCC: MS-DRG 291 • Pulmonary edema and respiratory failure: MS-DRG 189 • Cardiac defibrillator implant without cardiac catheterization with MCC: MS-DRG 226


• Cholecystectomy except by laparoscope without C.D.E. with CC: MS-DRG 415 • Major cardiovascular procedures with MCC or thoracic aortic aneurysm repair: MS-DRG 237 • HIV with extensive O.R. procedure with MCC: MS-DRG 969 • Extensive burns or full thickness burns with mechanical ventilation 96+ hours without skin graft: MS-DRG






Texas Region C/ Connolly



For non-medical necessity DRG validation reviews:• Upper Limb and Toe Amputation for Circulatory System Disorders with MCC: MS-DRG 255 • Cirrhosis and Alcoholic Hepatitis with MCC: MS- DRG 432 • Septicemia without Mechanical Ventilation 96+ Hours without MCC: MS-DRG 872 • Nonextensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC - MS-DRG 989 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987 • Other Respiratory System OR Procedures without CC/MCC: MS-DRG 168 • Extensive OR Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983 • Other Respiratory System OR Procedures with CC: MS-DRG 167 • Other Digestive System Diagnoses with CC: MS-DRG 394 • Inflammatory Bowel Disease with CC: MS-DRG 386 • Major Gastrointestinal Disorders and Peritoneal Infections without CC/MCC: MS-DRG 372 • Other Respiratory System OR Procedures with MCC: MS-DRG 166 • Major Small and Large Bowel Procedures without CC/MCC: MS-DRG 331 • Major Small and Large Bowel Procedures with CC: MS-DRG 330 • Major Small and Large Bowel Procedures with MCC: MS- DRG 329 • Major Chest Procedures without CC/MCC: MS-DRG 165 • Major Chest Procedures with MCC: MS-DRG 163 • Major Chest Procedures with CC: MS-DRG 164 • Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207


• Septicemia without Mechanical Ventilation 96+ Hours with MCC: MS-DRG 871 • Extensive OR Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981 • Extensive OR Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982 • Nonextensive OR Procedure Unrelated to Principal Diagnosis with CC - MS-DRG 988 • Coagulation Disorders: MS-DRG 813 • Peritoneal Adhesiolysis with MCC: MS-DRG 335 • Nonextensive Burns: MS-DRG 935 • Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674 • Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928 • OR Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876 • Infectious and Parasitic Diseases with OR Procedure without CC/MCC: MS-DRG 855 • Infectious and Parasitic Diseases with OR Procedure with CC: MS-DRG 854 • Postoperative or Posttraumatic Infections with OR Procedure without CC/MCC: MS-DRG 858 • Infectious and Parasitic Diseases with OR Procedure with MCC: MS-DRG 853 • Postoperative or Posttraumatic Infections with OR Procedure with CC: MS-DRG 857 • Postoperative or Posttraumatic Infections with OR Procedure with MCC: MS-DRG 856 • Wound Debridements for Injuries with CC: MS-DRG 902 • Wound Debridements for Injuries with MCC: MS-DRG 901 • Wound Debridements for Injuries without CC/MCC: MS-DRG 903 • Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673 • Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256 • Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC:









with MCC: MS-DRG 222• Pneumothorax without CC/MCC: MS-DRG 201 • Rehabilitation with CC/MCC: MS-DRG 945 • Major joint replacement or reattachment of lower extremity without MCC: MS-DRG 470 • Psychoses: MS-DRG 885 • Heart failure and shock with MCC: MS-DRG 291 • Pulmonary edema and respiratory failure: MS-DRG 189


• Cardiac defibrillator implant without cardiac catheterization with MCC: MS-DRG 226 • Cholecystectomy except by laparoscope without C.D.E. with CC: MS-DRG 415 • Major cardiovascular procedures with MCC or thoracic aortic aneurysm repair: MS-DRG 237 • HIV with extensive O.R. procedure with MCC: MS-DRG 969 • Extensive burns or full thickness burns with mechanical ventilation 96+ hours without skin graft: MS-DRG




DRG 041• Major bladder procedures with CC: MS-DRG 654 • Stomach, esophageal and duodenal procedures with CC: MS-DRG 327 • Rectal resection with CC: MS-DRG 333 • Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with CC: MS-DRG 217 For outpatient hospital and physician claims:• Once in a lifetime procedures • J2505: Injection, Pegfilgrastim, 6 mg • Medically Unlikely Edit List • Nebulizer, Demonstration and Evaluation Units Billed • Adenosine - Dose vs. Units billed • Barium Swallow Studies Units Billed

Utah Region D/HDI




For DMEMAC claims:• Urological bundling • Wheelchair Bundling


• Knee Orthotic Bundling • PEN supplies more than one time a day • Infusion Pump Denied/Accessories & Drug Codes should be denied • DMEPOS while patient is in a Covered Part A Inpatient Hospital Stay • SNF Consolidated Billing • A4221 Excessive Units • Prosthetic Bundling • DME while in Hospice • Medical Supplies and Home Health Consolidated billing • Date of Death-DME • Medically unlikely edits • DME duplicates • CPM device after three weeks





Vermont Region A/DCS

For DME supplier claims:• Pharmacy Supply and Dispensing Fees


• Wheelchair Bundling • Urological Bundling • Wheel Attachment with New Non-Wheeled Walker • Headrest with a Power Operated Vehicle or a Power Wheelchair with a Captain's Chair Seat • Multiple DME Rentals within a Month • Prosthetic Additions with Initial or Preparatory Knee Prosthesis • Lower Limb Suction Value Prosthesis • Solid Insert with Seat or Back Wheelchair Cushions • Oxygen Accessories









• MS-DRG validation for intracranial hemorrhage or cerebral infarction Virginia Region

C/ Connolly

For DME provider claims: (for all states who bill CIGNA Government Services)• Wheelchair bundling • Urological Bundling • Medically Unlikely Edit List

For DMEMAC claims: (for all states who bill CIGNA Government Services)• Budesonide - Dose vs. Billed Units • J7605 Arformoterol, (Brovana) • Q4099 Formoterol fumarate (perforomist)

For outpatient hospital and physician claims:• Barium Swallow Studies Units Billed (physician/carrier only)

Washington Region D/HDI




For DMEMAC claims:• Urological bundling


• Wheelchair Bundling • Knee Orthotic Bundling • PEN supplies more than one time a day • Infusion Pump Denied/Accessories & Drug Codes should be denied • DMEPOS while patient is in a Covered Part A Inpatient Hospital Stay • SNF Consolidated Billing • A4221 Excessive Units • Prosthetic Bundling • DME while in Hospice • Medical Supplies and Home Health Consolidated billing • Date of Death-DME • Medically unlikely edits • DME duplicates • CPM device after three weeks





For DME provider claims (for all states who bill CIGNA Government Services)


West Virginia Region C/ Connolly

• Wheelchair bundling • Urological Bundling

For DMEMAC claims:(for all states who bill CIGNA Government Services):• Wheelchair Bundling • Budesonide - Dose vs. Billed Units • J7605 Arformoterol, (Brovana) • Q4099 Formoterol fumarate (perforomist)

For outpatient hospital and physician claims:• Barium Swallow Studies Units Billed

Wisconsin Region B/CGI






























































• CAD versus unstable angina MS-DRG 311 Wyoming Region

D/HDIFor Part A outpatient and Part B claims:• Neulasta (HCPCS code J2505) • Newborn Pediatric CPT Codes Billed for Patients Exceeding Age Limit • Once in a Lifetime • Excessive Units—Untimed Codes • Excessive Units—Blood Transfusions • Excessive Units—Bronchoscopy • Excessive Units—IV Hydration • Global vs. TC/PC • Facility vs. Non-Facility Reimbursement (Inpatient) • SNF Consolidated Billing • Anesthesia Care Package E&M Services • NCCI Edits • Hospice Related Services – B • TC of Radiology • Not a New Patient - Providers are only allowed to bill the CPT codes for New Patient visits if the patient has


• OP services within 72 hours of admit • Acute Hospital Readmissions without condition code B4 or 42 • Incorrect patient status-IRF • Medically unlikely edits (Part A Outpatient, Part B)


• CSW During Inpatient





630)• Eye Disorders (MSDRGS 121-125) • Female Reproductive System Disorders (MSDRGS 754,-761) • HIV Infections (MSDRGS 969, 970, 974, 975, 976, 977) • Infection, Other (MSDRGS 075, 076, 864, 865, 866) • Joint Procedures (MSDRGS 461, 462, 466-470, 480-489, 492-494, 498, 499, 503-514, 535, 536, 906) • Male Reproductive System Disorders (MSDRGS 754-761) • M usculoskeletal Disorders (MSDRGS 539, 540, 541, 545-558, 564, 565, 566) • Musculoskeletal Fractures (MSDRGS 495, 496, 497, 533, 534, 537, 538, 542, 543, 544, 562, 563)


• Skin Disorders (MSDRGS 592, 593, 594, 595, 596, 602, 603, 604, 605, 606, 607) • Disorders Related to Injuries, Toxicity (MSDRGS 913, 914, 915, 916, 917, 918, 919, 920, 921, 922, 923)


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