July 14th Connolly Healthcare - the RAC for Region C - added 9 new CMS approved issues.

The issues are listed below by provider category, with the new issues in red.

 

For DME provider claims:

Wheelchair bundling

Urological Bundling
DME vs. Inpatient

 

For DMEMAC claims:

Budesonide - Dose vs. Billed Units

J7605 Arformoterol, (Brovana)

Q4099 Formoterol fumarate (perforomist)

For inpatient hospital claims:
Inpatient Admissions without a Physician's Inpatient Admit Order

 

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
Darbepoetin alfa (ESRD) - Dose vs. Units Billed
Irinotecan - Dose vs. Units Billed
Docetaxel - Dose vs. Units
Carboplatin - Dose vs. Units Billed
Bevacizumab - Dose vs. Units Billed
Darbepoetin alfa (non-ESRD) - Dose vs. Units Billed
Zoledronic acid, (Zometa) - Dose vs. Units Billed
Paclitaxel - Dose vs. Units Billed
Cetuximab - Dose vs. Units Billed
Paclitaxel protein-bound particles - Dose vs. Units Billed
Tenecteplase - Dose vs. Units Billed
Pamidronate Disodium - Dose vs. Units Billed
Adenosine - Dose vs. Units Billed
Zoledronic acid (Reclast), 1 mg - Dose vs. 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 O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC - MS-DRG 989

Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987

Other Respiratory System O.R. Procedures without CC/MCC: MS-DRG 168

Extensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983

Other Respiratory System O.R. 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 O.R. 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 O.R. Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981

Extensive O.R. Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982

Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with CC - MS-DRG 988

Coagulation Disorders: MS-DRG 813

Peritoneal Adhesiolysis with MCC: MS-DRG 335 (At this time, Medical Necessity excluded from review)

Nonextensive Burns: MS-DRG 935 (At this time Medical Necessity excluded from review)

Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674 (At this time Medical Necessity excluded from review)

Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928 (At this time Medical Necessity excluded from review)

O.R. Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876 (At this time Medical Necessity excluded from review)

Infectious and Parasitic Diseases with O.R. Procedure without CC/MCC: MS-DRG 855 (At this time Medical Necessity excluded from review)

Infectious and Parasitic Diseases with O.R. Procedure with CC: MS-DRG 854 (At this time Medical Necessity excluded from review)

Postoperative or Posttraumatic Infections with O.R. Procedure without CC/MCC: MS-DRG 858 (At this time Medical Necessity excluded from review)

Infectious and Parasitic Diseases with O.R. Procedure with MCC: MS-DRG 853 (At this time, Medical Necessity excluded from review)

Postoperative or Posttraumatic Infections with O.R. Procedure with CC: MS-DRG 857 (At this time, Medical Necessity excluded from review)

Postoperative or Posttraumatic Infections with O.R. Procedure with MCC: MS-DRG 856 (At this time Medical Necessity excluded from review)

Wound Debridements for Injuries with CC: MS-DRG 902 (At this time Medical Necessity excluded from review)

Wound Debridements for Injuries with MCC: MS-DRG 901 (At this time Medical Necessity excluded from review)

Wound Debridements for Injuries without CC/MCC: MS-DRG 903 (At this time Medical Necessity excluded from review)

Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673 (At this time Medical Necessity excluded from review)
Pulmonary Edema and Respiratory Failure: MS-DRG 189 (At this time, Medical Necessity excluded from review).
Heart Failure and Shock with MCC: MS-DRG 291 (At this time, Medical Necessity excluded from review).
Psychoses: MS-DRG 885 (At this time, Medical Necessity excluded from review).
Major Joint Replacement or Reattachment of Lower Extremity without MCC: MS-DRG 470 (At this time, Medical Necessity excluded from review).
Rehabilitation with CC/MCC: MS-DRG 945 (At this time, Medical Necessity excluded from review).
Pneumothorax without CC/MCC: MS-DRG 201 (At this time, Medical Necessity excluded from review).
Cardiac Defibrillator Implant with Cardiac Catheterization with Acute Myocardial Infarction/Heart Failure/Shock with MCC: MS-DRG 222 (At this time, Medical Necessity excluded from review).
Percutaneous Cardiovascular Procedure with Non Drug-Eluting Stent with MCC or 4 Vessels/Stents: MS-DRG 248 (At this time, Medical Necessity excluded from review).
Spinal Fusion Except Cervical with MCC: MS-DRG 460 (At this time, Medical Necessity excluded from review).
Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with MCC: MS-DRG 216 (At this time, Medical Necessity excluded from review).
Fractures of Femur with MCC: MS-DRG 533 (At this time, Medical Necessity excluded from review).
Knee Procedures without Principal Diagnosis of Infection with CC/MCC: MS-DRG 488 (At this time, Medical Necessity excluded from review).
Minor Small and Large Bowel Procedures with MCC: MS-DRG 344 (At this time, Medical Necessity excluded from review.
Other O.R. Procedures for Multiple Significant Trauma with MCC: MS-DRG 957 (At this time, Medical Necessity excluded from review).

Permanent Cardiac Pacemaker Implant with MCC: MS-DRG 242 (At this time, Medical Necessity excluded from review).
Amputation for Circulatory System Disorders Except Upper Limb and Toe with CC: MS-DRG 240 (At this time, Medical Necessity excluded from review).
Cardiac Defibrillator Implant without Cardiac Catheterization without MCC: MS-DRG 227 (At this time, Medical Necessity excluded from review).
Extracranial Procedures with CC: MS-DRG 038 (At this time, Medical Necessity excluded from review).
Respiratory System Diagnosis with Ventilator Support < 96 Hours: MS-DRG 208 (At this time, Medical Necessity excluded from review).
Other Male Reproductive System O.R. Procedures except Malignancy with CC/MCC: MS-DRG 717 (At this time, Medical Necessity excluded from review)
Other Kidney and Urinary Tract Procedures without CC/MCC: MS-DRG 675 (At this time, Medical Necessity excluded from review)
Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders with MCC: MS-DRG 616 (At this time, Medical Necessity excluded from review)
Other Hepatobiliary or Pancreas O.R. Procedures with CC: MS-DRG 424 (At this time, Medical Necessity excluded from review)
Other Ear, Nose, Mouth and Throat O.R. Procedures with CC/MCC: MS-DRG 133 (At this time, Medical Necessity excluded from review)
Other Digestive System O.R. Procedures without CC/MCC: MS-DRG 358 (At this time, Medical Necessity excluded from review)
Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with CC: MS-DRG 577 (At this time Medical Necessity excluded from review)
O.R. Procedure with Diagnoses of Other Contact with Health Services without CC/MCC: MS-DRG 941 (At this time Medical Necessity excluded from review)
Knee Procedures with Principal Diagnosis of Infection with CC: MS-DRG 486 (At this time, Medical Necessity excluded from review)
Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Other O.R. Procedure with CC/MCC: MS-DRG 829 (At this time Medical Necessity excluded from review)
Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders with CC: MS-DRG 617 (At this time Medical Necessity excluded from review)
Other Circulatory System Diagnoses with CC: MS-DRG 315 (At this time Medical Necessity excluded from review)
Lymphoma and Nonacute Leukemia with Other O.R. Procedure with MCC: MS-DRG 823 (At this time, Medical Necessity excluded from review)
Other O.R. Procedures of the Blood and Blood-Forming Organs with CC: MS-DRG 803 (At this time, Medical Necessity excluded from review)
Other Female Reproductive System O.R. Procedures with CC/MCC: MS-DRG 749 (At this time, Medical Necessity excluded from review)
Other Vascular Procedures with CC: MS-DRG 253 (At this time, Medical Necessity excluded from review)
Percutaneous Cardiovascular Procedure with Drug-Eluting Stent with MCC or 4 Vessels/Stents: MS-DRG 246 (At this time, Medical Necessity excluded from review)
Permanent Cardiac Pacemaker Implant with CC: MS-DRG 243 (At this time, Medical Necessity excluded from review)
Full Thickness Burn without Skin Graft or Inhalation Injury: MS-DRG 934 (At this time, Medical Necessity excluded from review)
Amputation for Circulatory System Disorders Except Upper Limb and Toe with MCC: MS-DRG 239 (At this time, Medical Necessity excluded from review)
Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96 Hours without Skin Graft: MS-DRG 933 (At this time, Medical Necessity excluded from review)
HIV with Extensive O.R. Procedure with MCC: MS-DRG 969 (At this time, Medical Necessity excluded from review)
Major Cardiovascular Procedures with MCC or Thoracic Aortic Aneurysm Repair: MS-DRG 237 (At this time, Medical Necessity excluded from review)
Cholecystectomy Except by Laparoscope without C.D.E. with CC: MS-DRG 415 (At this time, Medical Necessity excluded from review)
Cardiac Defibrillator Implant without Cardiac Catheterization with MCC: MS-DRG 226 (At this time, Medical Necessity excluded from review)
Peripheral/Cranial Nerve and Other Nervous System Procedures with CC or Peripheral Neurostimulator: MS-DRG 041
Stomach, Esophageal and Duodenal Procedures with CC: MS-DRG 327
Rectal Resection with CC: MS-DRG 333
Major Bladder Procedures with CC: MS-DRG 654
Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with CC: MS-DRG 217
Respiratory Infections & Inflammations without CC/MCC: MS-DRG 179
Respiratory Infections & Inflammations with CC: MS -DRG 178
Respiratory Infections & Inflammations with MCC: MS-DRG 177
Splenectomy w MCC, w CC, w/o CC/MCC
Bilateral or Multiple Major Joint Procedures of Lower Extremity with MCC: MS-DRG 461
Viral Meningitis without CC/MCC: MS-DRG 076
Lung Transplant: MS-DRG 007
Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis without MCC: MS-DRG 024
Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis with MCC or Chemo Implant: MS-DRG 023
Full Thickness Burn with Skin Graft or Inhalation Injury without CC/MCC: MS-DRG 929
Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours with Skin Graft: MS-DRG 927
Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with CC: MS-DRG 021
Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with MCC: MS-DRG 020
Tracheotomy for Face, Mouth, and Neck Diagnoses with CC MS-DRG 012
Tracheotomy for Face, Mouth, and Neck Diagnoses with MCC: MS-DRG 011
Kidney Transplant: MS-DRG 652
Rectal Resection with MCC: MS-DRG 332
Liver Transplant with MCC or Intestinal Transplant: MS-DRG 005
Heart Transplant or Implant of Heart Assist System with MCC - MS-DRG 001
ECMO or Tracheotomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R.: MS-DRG 003
Cardiac Procedures
Osteomyelitis without CC/MCC: MS-DRG 541
Other O.R. Procedures of the Blood and Blood-Forming Organs with MCC: MS-DRG 802
Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with CC: MS-DRG 623
Stomach, Esophageal and Duodenal Procedures without CC/MCC: MS-DRG 328
Bone Marrow Transplant: MS-DRG 009
Stomach, Esophageal and Duodenal Procedures with MCC: MS-DRG 326
Kidney and Ureter Procedures for Non-Neoplasm with MCC: MS-DRG 659
Major Bladder Procedure with MCC: MS-DRG 653
Cardiac Pacemaker Device Replacement with MCC: MS-DRG 258
Lymphoma and Nonacute Leukemia with CC: MS-DRG 841
Peripheral/Cranial Nerve and Other Nervous System Procedures with MCC: MS-DRG 040
Percutaneous Cardiovascular Procedure with Drug-Eluting Stent without MCC: MS-DRG 247 (At this time, Medical Necessity excluded from review).
Zoledronic acid, (Zometa) - Dose vs. Units Billed - Overpayment (At this time, Medical Necessity will be excluded from this review).
Lymphoma and Nonacute Leukemia with MCC: MS-DRG 840 (At this time, Medical Necessity excluded from review).
Disorders of Pancreas Except Malignancy without CC/MCC: MS-DRG 440 (At this time Medical Necessity excluded from review).
Endocrine, Nutritional & Metabolic Disorders (At this time, Medical Necessity Excluded).