Section 4070, Referrals , contains revised information of former '4210. It also specifies that the intermediary refer cases received via its Office of Inspector General hotline when related to quality of care complaints. PROs are to review these cases following the instructions in Part 5, ''5200 through 5280. PROs are also to refer cases to the intermediary involving billing issues. Section 4100, Introduction , provides the basic case review activities PROs are required to perform to fulfill the mandatory review requirements.
PROs are to be alert for potential quality concerns regardless of the reason for review.
Section 4110, Admission Review , contains revised information of former '4105. It provides instructions to conduct admission review to determine whether inpatient hospital care was medically necessary and appropriate for the diagnosis and condition of the patient at any time during the stay. PROs are to use the medical record and appropriate criteria to determine if an admission to a PPS or non-PPS hospital should be referred for physician review. Section 4115, Invasive Procedure Review , contains revised information of former '4215. The PROs are to determine if the invasive procedures performed were reasonable and medically necessary, and if the quality of care met professionally recognized standards of medical care.