Source: https://racinfo.hms.com/Public1/NewIssues.aspx
Timestamp: 2019-04-20 06:39:40+00:00

Document:
All new issues that are identified by HMS must first be approved by CMS.
Complex Inpatient Hospital MS-DRG Coding Validation MS-DRG Coding requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will code MS-DRGs for principal and secondary diagnosis and procedures affecting or potentially affecting the MS-DRG assignment. 0001 Inpatient Acute Care Hospital Complex 11/23/2016 04/13/2017 All Region 4 states AB MACs claims that have a "claim paid date" which is less than 3 years prior to the Medical Record Request date (complex review). 1. CMS Program Integrity Manual Ch. 6.5.3 A-C DRG Validation Review, 2. CMS QIO Manual Section 4130, 3. ICD-9 & 10 CM Coding Manual, 4. ICD-9 & 10 CM Addendums , 5. ICD-9 & 10 CM Official Guidelines for Coding and Reporting, and Addendums 6. ICD-10 Procedural Coding System (PCS) Coding Manual, Official Guidelines for Coding and Reporting, and Addendums 7. Coding Clinic for ICD-10-CM and ICD-10-PCS.
Add-on codes paid without required Primary Code – by Physician/ASC/Lab and Outpatient claims CPT has designated certain codes as "add-on procedures". These services are always done in conjunction with another procedure and are only payable when an appropriate primary service is also billed. 0050 Outpatient Hospital; Professional Services (Physician/Non-Physician Practitioner) Automated Review 02/14/2017 06/19/2017 All Region 4 states AB MACs claims that have a "claim paid date" which is less than 3 years prior to the Informational Letter date. 1. Social Security Act, Section 1833. [42 U.S.C. 1395l] (e) 2. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 30 D. 3. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 01, § 70 4. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 16, § 40.8 5. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 29, § 240 (revised 7/23/2013) 6. Medicare Claims Processing: Pub 100-04; Change Request CR9844 (effective 01/01/2017), I. b.
Excessive Units of Hospital Services Both Initial Hospital Care codes (CPT codes 99221–99223) and Subsequent Hospital Care codes (CPT Codes 99231-99233) are “per diem” services and may be reported only once per day by the same physician(s) of the same specialty from the same group practice. 0037 Professional Services (Physician/Non-Physician Practitioner) Automated Review 02/23/2017 04/13/2017 All Region 4 States AB MACs claims that have a "claim paid date" which is less than 3 years prior to the Informational Letter date. 1. Title XVIII of the Social Security Act (SSA), Section 1833(e) 2. 42 Code of Federal Regulations §424.5(a)(6) 3. Medicare Claims Processing Manual: Publication 100-04; Chapter 12, § 30.6.9 4. American Medical Association (AMA), Current Procedure Terminology 2013 to present.

References: § 30
 § 70
 § 40
 § 240
 §424
 § 30