The following provides detailed information related to MS-DRG services currently on FCSO’s prepayment medical review MS-DRG strategy. The MAC J9 CERT payment error findings are included for claims sampled in the November 2010 and November 2011 report periods. Denial information is also provided for those services previously subject to FCSO medical review activities.
226 — Cardiac defibrillator implant without (w/o) cardiac catheter with (w/) major complications or comorbidities (MCC); Applicable NCD: 20.4
CERT error findings:
• 60 percent did not meet the NCD criteria for the procedure, and the admission was not medically reasonable and necessary for an inpatient level of care
• 20 percent did not meet the NCD criteria for the procedure, but the admission was reasonable and necessary, and the patient met inpatient level of care. The admission was allowed with a revised MS-DRG code after removal of the denied procedure
• 20 percent met the NCD criteria and inpatient level of care, but the MS-DRG was re-coded based on complications or comorbidities
227 — Cardiac defibrillator implant w/o cardiac catheter w/o MCC; Applicable NCD: 20.4
CERT error findings:
• 70 percent met the NCD criteria for the procedure, but the admission was not reasonable and necessary for an inpatient level of care
• 20 percent did not meet the NCD criteria for the procedure, and the admission was not reasonable and necessary for an inpatient level of care
• 10 percent did not meet the NCD criteria for the procedure, but the admission was reasonable and necessary for an impatient level of care. The admission was allowed with a revised MS-DRG code after removal of the denied procedure
242 — Permanent cardiac pacemaker implant with MCC; Applicable NCD: 20.8
CERT error findings:
• 86 percent did not meet the NCD criteria for the procedure, but the admission was reasonable and necessary for an inpatient level of care. The admission was allowed with a revised MS-DRG code after removal of the denied procedure
• 14 percent did not meet the NCD criteria for the procedure, and the admission was not reasonable and necessary for an inpatient level of care.
243 — Permanent cardiac pacemaker implant with CC; Applicable NCD: 20.8
CERT error findings:
• 100 percent did not meet the NCD criteria for the procedure, but the admission was reasonable and necessary for an inpatient level of care. The admission was allowed with a revised MS-DRG code after removal of the denied procedure
244 — Permanent cardiac pacemaker implant w/o CC or MCC; Applicable NCD: 20.8
CERT error findings:
• 69 percent did not meet the NCD criteria for the procedure, but the admission was reasonable and necessary for an inpatient level of care. The admission was allowed with a revised MS-DRG code after removal of the denied procedure
• 19 percent did not meet the NCD criteria for the procedure, and the admission was not reasonable and necessary for an inpatient level of care.
• 6 percent met the NCD criteria for the procedure, and the admission was reasonable and necessary for an inpatient level of care; however, there was miscoding in the DRG and the service was recoded
• 6 percent met the NCD criteria for the procedure, but the admission was not reasonable and necessary for an inpatient level of care.
245 — Automatic implantable cardiac defibrillator (AICD) generator procedures; Applicable NCD: 20.4
CERT error findings:
• 100 percent met the NCD criteria for the procedure, but the admission was not reasonable and necessary for an inpatient level of care.
247 — Percutaneous cardiovascular procedure with drug-eluting stent w/o MCC; Applicable NCD: 20.7
CERT error findings:
• 100 percent met the NCD criteria for the procedure, but the admission was not reasonable and necessary for an inpatient level of care
251 — Percutaneous cardiovascular procedure w/o coronary artery stent w/o MCC; Applicable NCD: 20.7
CERT error findings:
• 100 percent met the NCD criteria for the procedure, but the admission was not reasonable and necessary for an inpatient level of care
253 — Other vascular procedures with CC; Applicable NCD: N/A
CERT error findings:
• There were no MAC J9 error findings; however, nationally, most services were denied as the admission was not reasonable and necessary for an inpatient level of care
264 — Other circulatory system O.R. procedures; Applicable NCD: N/A
CERT error findings:
• In 100 percent of these cases, the procedure was reasonable and necessary, but the admission was not reasonable and necessary for an inpatient level of care
287 — Circulatory disorders except acute myocardial infarction (AMI), with cardiac catheter w/o MCC; Applicable NCD: 20.7
CERT error findings:
• In 80 percent of these cases, the procedure was reasonable and necessary, but the admission was not reasonable and necessary for an inpatient level of care
• In 20 percent of these cases, the procedure was not considered reasonable and necessary, and the admission was not reasonable and necessary for an inpatient level of care
313 — Chest pain; Applicable NCD: N/A
CERT error findings:
• 100 percent were denied as the admission was not reasonable and necessary for an inpatient level of care
FCSO prepayment review findings:
• 30 percent prepayment edit implemented on March 1, 2011, with an 81.6 percent denial rate to date
• Most were denied as the admission was not reasonable and necessary for an inpatient level of care
392 — Esophagitis, gastroenteritis, and miscellaneous digestive disorders w/o MCC; Applicable NCD: N/A
CERT error findings:
• 100 percent were denied as the admission was not reasonable and necessary for an inpatient level of care
458 — Spinal fusion except cervical with spinal curve/malign/infection or 9+ fusions w/o CC/MCC Applicable NCD: N/A; Applicable LCD: Lumbar Spinal Fusion for Instability and Degenerative Disc Conditions (L32074)
CERT error findings:
• In 100 percent of these cases, the procedure was reasonable and necessary, but the admission was not reasonable and necessary for an inpatient level of care (the billed spinal fusion procedure code was not on the inpatient-only list)
460 — Spinal fusion except cervical w/o MCC; Applicable NCD: N/A; Applicable LCD: Lumbar Spinal Fusion for Instability and Degenerative Disc Conditions (L32074)
CERT error findings:
• In 60 percent of these cases, the documentation did not support that the procedure was reasonable and necessary
• In 20 percent of these cases, the procedure was reasonable and necessary, but there was no physician’s order for admission
• In 20 percent of these cases, the procedure was reasonable and necessary, but the admission was not reasonable and necessary for an inpatient level of care (the billed spinal fusion procedure codes were not on the inpatient-only list)
FCSO prepayment review findings:
• 30 percent prepayment edit implemented on June 23, 2011, with a 41 percent denial rate to date
• Most were denied as the documentation did not support that the procedure was reasonable and necessary
470 — Major joint replacement or reattachment of lower extremity w/o MCC; Applicable NCD: N/A; Applicable LCD: Major Joint Replacement (Hip and Knee) (L32078)
CERT error findings:
• In 92 percent of these cases, the documentation did not support that the procedure was reasonable and necessary
• In 8 percent of these cases, the procedure was reasonable and necessary, but the admission was not reasonable and necessary for an inpatient level of care (the billed knee replacement procedure code was not on the inpatient-only list)
FCSO prepayment review findings:
• 30 percent prepayment edit implemented on June 1, 2011, with a 62 percent denial rate to date
• Most were denied as the documentation did not support that the procedure was reasonable and necessary
490 — Back and neck procedures except spinal fusion with CC/MCC or disc device/neurostimulator; Applicable NCD: N/A
CERT error findings:
• In 100 percent of these cases, the procedure was reasonable and necessary, but the admission was not reasonable and necessary for an inpatient level of care
552– Medical back problems w/o MCC; Applicable NCD: N/A
CERT error findings: N/A
FCSO prepayment review findings:
• 30 percent prepayment edit implemented on April 1, 2011, with a 70 percent denial rate to date
• Most were denied as the admission was not reasonable and necessary for an inpatient level of care
641– Miscellaneous disorders of nutrition, metabolism, fluids/electrolytes w/o MCC; Applicable NCD: N/A
CERT error findings:
• 100 percent were denied as the admission was not reasonable and necessary for an inpatient level of care
NCD References:
• Medicare National Coverage Determinations Manual, Chapter 1, Part 1 (Sections 10 — 80.12)
• NCD 20.4 — Implantable Automatic Defibrillators
• NCD 20.7 — Percutaneous Transluminal Angioplasty (PTA)
• NCD 20.8 — Cardiac Pacemakers