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Region D: RAC approved issues by state
(Updated 3-1-11)
State
Alaska
Region/ RAC
Region D/HDI
Approved Issues (Claim type)
For Part A claims:
 SNF Consolidated Billing
 Hospice Related Services – B
 Acute Hospital Readmissions without condition code B4 or 42
 Incorrect patient status-IRF
 Minor surgery and other treatment billed as an inpatient stay
 Acute inpatient hospitalization – infections
 Acute inpatient hospitalization - musculoskeletal disorders
 Acute inpatient hospitalization - respiratory conditions
 Acute inpatient hospitalization - neurological disorders
 Gastrointestinal disorders billed as an inpatient stay
 Nervous system disorders billed as an inpatient stay
 Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
 OP services within 72 hours of admit
 Neulasta (HCPCS code J2505)
 Medically unlikely edits
For Part B claims:
 Global vs. TC/PC
 Facility vs. Non-Facility Reimbursement (Inpatient)
 NCCI Edits
 Hospice Related Services – B
 TC of Radiology
 Not a New Patient
 Medically unlikely edits
 CSW During Inpatient
 Ambulance during inpatient
 Ambulance SNF to SNF transfer (NN Modifier)
 Date of death
 Part B duplicates - automated review
 Co-surgery not billed with modifier 62
 Global days
 Anesthesia care package E/M services
 Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
 Procedures performed during the global period of other procedures
 Multiple surgery reduction errors: single line modifier 51 underpayments
 Multiple surgery reduction errors - underpayments
 Multiple surgery reduction errors – overpayments
 Wheelchair seating, mutually exclusive codes
 AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
 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
For inpatient hospital claims:
 Inpatient admissions without a physician's inpatient admit order
For DME 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
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

DME duplicates
CPM device after three weeks
Complex review of lower limb prosthetics
Therapeutic footwear utilization
Mobility durable medical equipment paid after claim patient lift paid
Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD)
accessories
Overutilization of nebulizer medications
Lower limb suction valve prosthetics
Breast prosthetics allowed one a side
Transcutaneous electrical nerve stimulators (TENS) supplies bundling
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)
 Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263,
264)
 Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
 Eye procedures (MS-DRGs 113-117)
 Female reproductive system procedures (MS-DRGs 734-750)
 Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)
 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 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)
 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 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)
 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) 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)
 Incorrect patient status-acute
For medical necessity DRG validation claims:
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

DRG validation-cardiovascular, other (Medical necessity review may be performed for MS
DRG 312 only)
DRG validation-musculoskeletal disorders (Medical necessity review may be performed for
MS DRGs 551 and 552 only.)
DRG validation-blood and immunological disorders (Medical necessity review may be
performed for MS DRG 811 only.)
DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS
DRGs 253, 254, 291-293, 302, 308, 313-316 only.)
DRG validation-nervous system disorders (Medical necessity review may be performed for
MS DRGs 056, 057 and 069 only.)
DRG validation-kidney and urinary tract disorders (Medical necessity review may be
performed for MS DRGs 682-684 and 689 only.)
DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be
performed for MS DRG 640 only.)
DRG validation-gastrointestinal disorders (Medical necessity review may be performed for
MS DRGs 391 and 393 only.)
DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG
249 only.)


Arizona
Region D/HDI
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS
DRGs 190, 191 and 192 only.)
DRG validation-cardiovascular procedures (253 and 254 only)
For Part A claims:
 SNF Consolidated Billing
 Hospice Related Services – B
 Acute Hospital Readmissions without condition code B4 or 42
 Incorrect patient status-IRF
 Minor surgery and other treatment billed as an inpatient stay
 Acute inpatient hospitalization – infections
 Acute inpatient hospitalization - musculoskeletal disorders
 Acute inpatient hospitalization - respiratory conditions
 Acute inpatient hospitalization - neurological disorders
 Gastrointestinal disorders billed as an inpatient stay
 Nervous system disorders billed as an inpatient stay
 Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
 OP services within 72 hours of admit
 Neulasta (HCPCS code J2505)
 Medically unlikely edits
For Part B claims:
 Global vs. TC/PC
 Facility vs. Non-Facility Reimbursement (Inpatient)
 NCCI Edits
 Hospice Related Services – B
 TC of Radiology
 Not a New Patient
 Medically unlikely edits
 CSW During Inpatient
 Ambulance during inpatient
 Ambulance SNF to SNF transfer (NN Modifier)
 Date of death
 Part B duplicates - automated review
 Co-surgery not billed with modifier 62
 Global days
 Anesthesia care package E/M services
 Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
 Procedures performed during the global period of other procedures
 Multiple surgery reduction errors: single line modifier 51 underpayments
 Multiple surgery reduction errors - underpayments
 Multiple surgery reduction errors – overpayments
 Wheelchair seating, mutually exclusive codes
 AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
 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
For inpatient hospital claims:
 Inpatient admissions without a physician's inpatient admit order
For DME 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
 Complex review of lower limb prosthetics
 Therapeutic footwear utilization
 Mobility durable medical equipment paid after claim patient lift paid
 Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD)




accessories
Overutilization of nebulizer medications
Lower limb suction valve prosthetics
Breast prosthetics allowed one a side
Transcutaneous electrical nerve stimulators (TENS) supplies bundling
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)
 Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263,
264)

Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
 Eye procedures (MS-DRGs 113-117)
 Female reproductive system procedures (MS-DRGs 734-750)
 Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)

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 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)

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 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)
 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)
 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)
 Incorrect patient status-acute
For medical necessity DRG validation claims:

DRG validation-cardiovascular, other (Medical necessity review may be performed for MS
DRG 312 only)

DRG validation-musculoskeletal disorders (Medical necessity review may be performed for
MS DRGs 551 and 552 only.)

DRG validation-blood and immunological disorders (Medical necessity review may be
performed for MS DRG 811 only.)

DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS
DRGs 253, 254, 291-293, 302, 308, 313-316 only.)

DRG validation-nervous system disorders (Medical necessity review may be performed for
MS DRGs 056, 057 and 069 only.)

DRG validation-kidney and urinary tract disorders (Medical necessity review may be
performed for MS DRGs 682-684 and 689 only.)

DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be
performed for MS DRG 640 only.)

DRG validation-gastrointestinal disorders (Medical necessity review may be performed for
MS DRGs 391 and 393 only.)

DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG
249 only.)
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS
DRGs 190, 191 and 192 only.)

DRG validation-cardiovascular procedures (253 and 254 only)
California
Region D/HDI
For Part A claims:
 SNF Consolidated Billing
 Hospice Related Services – B
 Acute Hospital Readmissions without condition code B4 or 42
 Incorrect patient status-IRF
 Minor surgery and other treatment billed as an inpatient stay
 Acute inpatient hospitalization – infections
 Acute inpatient hospitalization - musculoskeletal disorders
 Acute inpatient hospitalization - respiratory conditions
 Acute inpatient hospitalization - neurological disorders
 Gastrointestinal disorders billed as an inpatient stay
 Nervous system disorders billed as an inpatient stay
 Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
 OP services within 72 hours of admit
 Neulasta (HCPCS code J2505)
 Medically unlikely edits
For Part B claims:
 Global vs. TC/PC
 Facility vs. Non-Facility Reimbursement (Inpatient)
 NCCI Edits
 Hospice Related Services – B
 TC of Radiology
 Not a New Patient
 Medically unlikely edits
 CSW During Inpatient
 Ambulance during inpatient
 Ambulance SNF to SNF transfer (NN Modifier)
 Date of death
 Part B duplicates - automated review
 Co-surgery not billed with modifier 62
 Global days
 Anesthesia care package E/M services
 Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
 Procedures performed during the global period of other procedures
 Multiple surgery reduction errors: single line modifier 51 underpayments
 Multiple surgery reduction errors - underpayments
 Multiple surgery reduction errors – overpayments
 Wheelchair seating, mutually exclusive codes
 AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
 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
For inpatient hospital claims:
 Inpatient admissions without a physician's inpatient admit order
For DME 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
 Complex review of lower limb prosthetics
 Therapeutic footwear utilization
 Mobility durable medical equipment paid after claim patient lift paid
 Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD)
accessories
 Overutilization of nebulizer medications
 Lower limb suction valve prosthetics
 Breast prosthetics allowed one a side
 Transcutaneous electrical nerve stimulators (TENS) supplies bundling
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)

Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252,
253, 254, 263, 264)
 Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
 Eye procedures (MS-DRGs 113-117)
 Female reproductive system procedures (MS-DRGs 734-750)
 Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)
 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 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)

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 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)
 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)
 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)
 Incorrect patient status-acute
For medical necessity DRG validation claims:

DRG validation-cardiovascular, other (Medical necessity review may be performed for MS
DRG 312 only)

DRG validation-musculoskeletal disorders (Medical necessity review may be performed for
MS DRGs 551 and 552 only.)

DRG validation-blood and immunological disorders (Medical necessity review may be
performed for MS DRG 811 only.)

DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS
DRGs 253, 254, 291-293, 302, 308, 313-316 only.)

DRG validation-nervous system disorders (Medical necessity review may be performed for
MS DRGs 056, 057 and 069 only.)

DRG validation-kidney and urinary tract disorders (Medical necessity review may be
performed for MS DRGs 682-684 and 689 only.)

DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be
performed for MS DRG 640 only.)

DRG validation-gastrointestinal disorders (Medical necessity review may be performed for
MS DRGs 391 and 393 only.)

DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG
249 only.)
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS
DRGs 190, 191 and 192 only.)
Hawaii
Region D/HDI
For Part A claims:
 SNF Consolidated Billing
 Hospice Related Services – B
 Acute Hospital Readmissions without condition code B4 or 42
 Incorrect patient status-IRF
 Minor surgery and other treatment billed as an inpatient stay







Acute inpatient hospitalization – infections
Acute inpatient hospitalization - musculoskeletal disorders
Acute inpatient hospitalization - respiratory conditions
Acute inpatient hospitalization - neurological disorders
Gastrointestinal disorders billed as an inpatient stay
Nervous system disorders billed as an inpatient stay
Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
 OP services within 72 hours of admit
 Neulasta (HCPCS code J2505)
 Medically unlikely edits
For Part B claims:
 Global vs. TC/PC
 Facility vs. Non-Facility Reimbursement (Inpatient)
 NCCI Edits
 Hospice Related Services – B
 TC of Radiology
 Not a New Patient
 Medically unlikely edits
 CSW During Inpatient
 Ambulance during inpatient
 Ambulance SNF to SNF transfer (NN Modifier)
 Date of death
 Part B duplicates - automated review
 Co-surgery not billed with modifier 62
 Global days
 Anesthesia care package E/M services
 Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
 Procedures performed during the global period of other procedures
 Multiple surgery reduction errors: single line modifier 51 underpayments
 Multiple surgery reduction errors - underpayments
 Multiple surgery reduction errors – overpayments
 Wheelchair seating, mutually exclusive codes
 AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
 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
For inpatient hospital claims:
 Inpatient admissions without a physician's inpatient admit order
For DME 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
 Complex review of lower limb prosthetics
 Therapeutic footwear utilization
 Mobility durable medical equipment paid after claim patient lift paid
 Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD)
accessories
 Overutilization of nebulizer medications
 Lower limb suction valve prosthetics
 Breast prosthetics allowed one a side
 Transcutaneous electrical nerve stimulators (TENS) supplies bundling
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)
 Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263,
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264)
Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
Eye procedures (MS-DRGs 113-117)
Female reproductive system procedures (MS-DRGs 734-750)
Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)
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 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)
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 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)
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)
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)
Incorrect patient status-acute
For medical necessity DRG validation claims:

DRG validation-cardiovascular, other (Medical necessity review may be performed for MS
DRG 312 only)

DRG validation-musculoskeletal disorders (Medical necessity review may be performed for
MS DRGs 551 and 552 only.)

DRG validation-blood and immunological disorders (Medical necessity review may be
performed for MS DRG 811 only.)

DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS
DRGs 253, 254, 291-293, 302, 308, 313-316 only.)

DRG validation-nervous system disorders (Medical necessity review may be performed for
MS DRGs 056, 057 and 069 only.)

DRG validation-kidney and urinary tract disorders (Medical necessity review may be
performed for MS DRGs 682-684 and 689 only.)

DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be
performed for MS DRG 640 only.)

DRG validation-gastrointestinal disorders (Medical necessity review may be performed for
MS DRGs 391 and 393 only.)

DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG
249 only.)
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS
DRGs 190, 191 and 192 only.)

DRG validation-cardiovascular procedures (253 and 254 only)
Iowa
Region D/HDI
For Part A claims:
 SNF Consolidated Billing
 Hospice Related Services – B
 Acute Hospital Readmissions without condition code B4 or 42
 Incorrect patient status-IRF
 Minor surgery and other treatment billed as an inpatient stay
 Acute inpatient hospitalization – infections
 Acute inpatient hospitalization - musculoskeletal disorders
 Acute inpatient hospitalization - respiratory conditions
 Acute inpatient hospitalization - neurological disorders
 Gastrointestinal disorders billed as an inpatient stay
 Nervous system disorders billed as an inpatient stay

Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
 OP services within 72 hours of admit
 Neulasta (HCPCS code J2505)
 Medically unlikely edits
For Part B claims:
 Global vs. TC/PC
 Facility vs. Non-Facility Reimbursement (Inpatient)
 NCCI Edits
 Hospice Related Services – B
 TC of Radiology
 Not a New Patient
 Medically unlikely edits
 CSW During Inpatient
 Ambulance during inpatient
 Ambulance SNF to SNF transfer (NN Modifier)
 Date of death
 Part B duplicates - automated review
 Co-surgery not billed with modifier 62
 Global days
 Anesthesia care package E/M services
 Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
 Procedures performed during the global period of other procedures
 Multiple surgery reduction errors: single line modifier 51 underpayments
 Multiple surgery reduction errors - underpayments
 Multiple surgery reduction errors – overpayments
 Wheelchair seating, mutually exclusive codes
 AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
 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
For inpatient hospital claims:
 Inpatient admissions without a physician's inpatient admit order
For DME 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
 Complex review of lower limb prosthetics
 Therapeutic footwear utilization
 Mobility durable medical equipment paid after claim patient lift paid
 Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD)
accessories
 Overutilization of nebulizer medications
 Lower limb suction valve prosthetics
 Breast prosthetics allowed one a side
 Transcutaneous electrical nerve stimulators (TENS) supplies bundling
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)
 Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263,
264)
 Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
 Eye procedures (MS-DRGs 113-117)
 Female reproductive system procedures (MS-DRGs 734-750)
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Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)
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 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)
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 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)
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)
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)
Incorrect patient status-acute
For medical necessity DRG validation claims:

DRG validation-cardiovascular, other (Medical necessity review may be performed for MS
DRG 312 only)

DRG validation-musculoskeletal disorders (Medical necessity review may be performed for
MS DRGs 551 and 552 only.)

DRG validation-blood and immunological disorders (Medical necessity review may be
performed for MS DRG 811 only.)

DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS
DRGs 253, 254, 291-293, 302, 308, 313-316 only.)

DRG validation-nervous system disorders (Medical necessity review may be performed for
MS DRGs 056, 057 and 069 only.)

DRG validation-kidney and urinary tract disorders (Medical necessity review may be
performed for MS DRGs 682-684 and 689 only.)

DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be
performed for MS DRG 640 only.)

DRG validation-gastrointestinal disorders (Medical necessity review may be performed for
MS DRGs 391 and 393 only.)

DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG
249 only.)
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS
DRGs 190, 191 and 192 only.)

DRG validation-cardiovascular procedures (253 and 254 only)
Idaho
Region D/HDI
For Part A claims:
 SNF Consolidated Billing
 Hospice Related Services – B
 Acute Hospital Readmissions without condition code B4 or 42
 Incorrect patient status-IRF
 Minor surgery and other treatment billed as an inpatient stay
 Acute inpatient hospitalization – infections
 Acute inpatient hospitalization - musculoskeletal disorders
 Acute inpatient hospitalization - respiratory conditions
 Acute inpatient hospitalization - neurological disorders
 Gastrointestinal disorders billed as an inpatient stay
 Nervous system disorders billed as an inpatient stay
 Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
 OP services within 72 hours of admit
 Neulasta (HCPCS code J2505)
 Medically unlikely edits
For Part B claims:
 Global vs. TC/PC
 Facility vs. Non-Facility Reimbursement (Inpatient)
 NCCI Edits
 Hospice Related Services – B
 TC of Radiology
 Not a New Patient
 Medically unlikely edits
 CSW During Inpatient
 Ambulance during inpatient
 Ambulance SNF to SNF transfer (NN Modifier)
 Date of death
 Part B duplicates - automated review
 Co-surgery not billed with modifier 62
 Global days
 Anesthesia care package E/M services
 Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
 Procedures performed during the global period of other procedures
 Multiple surgery reduction errors: single line modifier 51 underpayments
 Multiple surgery reduction errors - underpayments
 Multiple surgery reduction errors – overpayments
 Wheelchair seating, mutually exclusive codes
 AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
 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
For inpatient hospital claims:
 Inpatient admissions without a physician's inpatient admit order
For DME 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
 Complex review of lower limb prosthetics
 Therapeutic footwear utilization
 Mobility durable medical equipment paid after claim patient lift paid
 Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD)
accessories
 Overutilization of nebulizer medications
 Lower limb suction valve prosthetics
 Breast prosthetics allowed one a side
 Transcutaneous electrical nerve stimulators (TENS) supplies bundling
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)
 Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263,
264)

Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
 Eye procedures (MS-DRGs 113-117)
 Female reproductive system procedures (MS-DRGs 734-750)
 Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)

Health status factors (MS-DRGs 939, 940, 941, 945-951)
 Infection (MS-DRGs 094, 095, 096, 853, 854, 855, 867, 868, 869)
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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)
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 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)
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)
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)
Incorrect patient status-acute
For medical necessity DRG validation claims:

DRG validation-cardiovascular, other (Medical necessity review may be performed for MS
DRG 312 only)

DRG validation-musculoskeletal disorders (Medical necessity review may be performed for
MS DRGs 551 and 552 only.)

DRG validation-blood and immunological disorders (Medical necessity review may be
performed for MS DRG 811 only.)

DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS
DRGs 253, 254, 291-293, 302, 308, 313-316 only.)

DRG validation-nervous system disorders (Medical necessity review may be performed for
MS DRGs 056, 057 and 069 only.)

DRG validation-kidney and urinary tract disorders (Medical necessity review may be
performed for MS DRGs 682-684 and 689 only.)

DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be
performed for MS DRG 640 only.)

DRG validation-gastrointestinal disorders (Medical necessity review may be performed for
MS DRGs 391 and 393 only.)

DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG
249 only.)
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS
DRGs 190, 191 and 192 only.)

DRG validation-cardiovascular procedures (253 and 254 only)
Kansas
Region D/HDI
For Part A claims:
 SNF Consolidated Billing
 Hospice Related Services – B
 Acute Hospital Readmissions without condition code B4 or 42
 Incorrect patient status-IRF
 Minor surgery and other treatment billed as an inpatient stay
 Acute inpatient hospitalization – infections
 Acute inpatient hospitalization - musculoskeletal disorders
 Acute inpatient hospitalization - respiratory conditions
 Acute inpatient hospitalization - neurological disorders
 Gastrointestinal disorders billed as an inpatient stay
 Nervous system disorders billed as an inpatient stay
 Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
 OP services within 72 hours of admit
 Neulasta (HCPCS code J2505)

Medically unlikely edits
For Part B claims:
 Global vs. TC/PC
 Facility vs. Non-Facility Reimbursement (Inpatient)
 NCCI Edits
 Hospice Related Services – B
 TC of Radiology
 Not a New Patient
 Medically unlikely edits
 CSW During Inpatient
 Ambulance during inpatient
 Ambulance SNF to SNF transfer (NN Modifier)
 Date of death
 Part B duplicates - automated review
 Co-surgery not billed with modifier 62
 Global days
 Anesthesia care package E/M services
 Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
 Procedures performed during the global period of other procedures
 Multiple surgery reduction errors: single line modifier 51 underpayments
 Multiple surgery reduction errors - underpayments
 Multiple surgery reduction errors – overpayments
 Wheelchair seating, mutually exclusive codes
 AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
 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
For inpatient hospital claims:
 Inpatient admissions without a physician's inpatient admit order
For DME 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
 Complex review of lower limb prosthetics
 Therapeutic footwear utilization
 Mobility durable medical equipment paid after claim patient lift paid
 Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD)
accessories
 Overutilization of nebulizer medications
 Lower limb suction valve prosthetics
 Breast prosthetics allowed one a side
 Transcutaneous electrical nerve stimulators (TENS) supplies bundling
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)
 Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263,
264)
 Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
 Eye procedures (MS-DRGs 113-117)
 Female reproductive system procedures (MS-DRGs 734-750)
 Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)

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 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)
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

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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 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)
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)
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)
Incorrect patient status-acute
For medical necessity DRG validation claims:

DRG validation-cardiovascular, other (Medical necessity review may be performed for MS
DRG 312 only)

DRG validation-musculoskeletal disorders (Medical necessity review may be performed for
MS DRGs 551 and 552 only.)

DRG validation-blood and immunological disorders (Medical necessity review may be
performed for MS DRG 811 only.)

DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS
DRGs 253, 254, 291-293, 302, 308, 313-316 only.)

DRG validation-nervous system disorders (Medical necessity review may be performed for
MS DRGs 056, 057 and 069 only.)

DRG validation-kidney and urinary tract disorders (Medical necessity review may be
performed for MS DRGs 682-684 and 689 only.)

DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be
performed for MS DRG 640 only.)

DRG validation-gastrointestinal disorders (Medical necessity review may be performed for
MS DRGs 391 and 393 only.)

DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG
249 only.)
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS
DRGs 190, 191 and 192 only.)

DRG validation-cardiovascular procedures (253 and 254 only)
Missouri
Region D/HDI
For Part A claims:
 SNF Consolidated Billing
 Hospice Related Services – B
 Acute Hospital Readmissions without condition code B4 or 42
 Incorrect patient status-IRF
 Minor surgery and other treatment billed as an inpatient stay
 Acute inpatient hospitalization – infections
 Acute inpatient hospitalization - musculoskeletal disorders
 Acute inpatient hospitalization - respiratory conditions
 Acute inpatient hospitalization - neurological disorders
 Gastrointestinal disorders billed as an inpatient stay
 Nervous system disorders billed as an inpatient stay
 Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
 OP services within 72 hours of admit
 Neulasta (HCPCS code J2505)
 Medically unlikely edits
For Part B claims:
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Global vs. TC/PC
Facility vs. Non-Facility Reimbursement (Inpatient)
NCCI Edits
Hospice Related Services – B
TC of Radiology
Not a New Patient
Medically unlikely edits
CSW During Inpatient
Ambulance during inpatient
Ambulance SNF to SNF transfer (NN Modifier)
Date of death
Part B duplicates - automated review
Co-surgery not billed with modifier 62
Global days
Anesthesia care package E/M services
Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
Procedures performed during the global period of other procedures
Multiple surgery reduction errors: single line modifier 51 underpayments
Multiple surgery reduction errors - underpayments
Multiple surgery reduction errors – overpayments
Wheelchair seating, mutually exclusive codes
AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
 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
For inpatient hospital claims:
 Inpatient admissions without a physician's inpatient admit order
For DME 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
 Complex review of lower limb prosthetics
 Therapeutic footwear utilization
 Mobility durable medical equipment paid after claim patient lift paid
 Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD)
accessories
 Overutilization of nebulizer medications
 Lower limb suction valve prosthetics
 Breast prosthetics allowed one a side
 Transcutaneous electrical nerve stimulators (TENS) supplies bundling
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)
 Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263,
264)
 Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
 Eye procedures (MS-DRGs 113-117)
 Female reproductive system procedures (MS-DRGs 734-750)
 Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)

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 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)

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)
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Neoplasm surgery (MS-DRGs 837-849)
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)
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)
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)
Incorrect patient status-acute
For medical necessity DRG validation claims:

DRG validation-cardiovascular, other (Medical necessity review may be performed for MS
DRG 312 only)

DRG validation-musculoskeletal disorders (Medical necessity review may be performed for
MS DRGs 551 and 552 only.)

DRG validation-blood and immunological disorders (Medical necessity review may be
performed for MS DRG 811 only.)

DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS
DRGs 253, 254, 291-293, 302, 308, 313-316 only.)

DRG validation-nervous system disorders (Medical necessity review may be performed for
MS DRGs 056, 057 and 069 only.)

DRG validation-kidney and urinary tract disorders (Medical necessity review may be
performed for MS DRGs 682-684 and 689 only.)

DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be
performed for MS DRG 640 only.)

DRG validation-gastrointestinal disorders (Medical necessity review may be performed for
MS DRGs 391 and 393 only.)

DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG
249 only.)
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS
DRGs 190, 191 and 192 only.)

DRG validation-cardiovascular procedures (253 and 254 only)
Montana
Region D/HDI
For Part A claims:
 SNF Consolidated Billing
 Hospice Related Services – B
 Acute Hospital Readmissions without condition code B4 or 42
 Incorrect patient status-IRF
 Minor surgery and other treatment billed as an inpatient stay
 Acute inpatient hospitalization – infections
 Acute inpatient hospitalization - musculoskeletal disorders
 Acute inpatient hospitalization - respiratory conditions
 Acute inpatient hospitalization - neurological disorders
 Gastrointestinal disorders billed as an inpatient stay
 Nervous system disorders billed as an inpatient stay
 Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
 OP services within 72 hours of admit
 Neulasta (HCPCS code J2505)
 Medically unlikely edits
For Part B claims:
 Global vs. TC/PC
 Facility vs. Non-Facility Reimbursement (Inpatient)
 NCCI Edits
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
Hospice Related Services – B
TC of Radiology
Not a New Patient
Medically unlikely edits
CSW During Inpatient
Ambulance during inpatient
Ambulance SNF to SNF transfer (NN Modifier)
Date of death
Part B duplicates - automated review
Co-surgery not billed with modifier 62
Global days
Anesthesia care package E/M services
Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
Procedures performed during the global period of other procedures
Multiple surgery reduction errors: single line modifier 51 underpayments
Multiple surgery reduction errors - underpayments
Multiple surgery reduction errors – overpayments
Wheelchair seating, mutually exclusive codes
AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
 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
For inpatient hospital claims:
 Inpatient admissions without a physician's inpatient admit order
For DME 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
 Complex review of lower limb prosthetics
 Therapeutic footwear utilization
 Mobility durable medical equipment paid after claim patient lift paid
 Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD)
accessories
 Overutilization of nebulizer medications
 Lower limb suction valve prosthetics
 Breast prosthetics allowed one a side
 Transcutaneous electrical nerve stimulators (TENS) supplies bundling
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)
 Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263,
264)
 Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
 Eye procedures (MS-DRGs 113-117)
 Female reproductive system procedures (MS-DRGs 734-750)
 Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)

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 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)

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 procedures (MS-DRGs 020-033 and 037-042)
 OR procedure unrelated to principal diagnosis (MS DRGs 981-989)

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











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)
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)
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)
Incorrect patient status-acute
For medical necessity DRG validation claims:

DRG validation-cardiovascular, other (Medical necessity review may be performed for MS
DRG 312 only)

DRG validation-musculoskeletal disorders (Medical necessity review may be performed for
MS DRGs 551 and 552 only.)

DRG validation-blood and immunological disorders (Medical necessity review may be
performed for MS DRG 811 only.)

DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS
DRGs 253, 254, 291-293, 302, 308, 313-316 only.)

DRG validation-nervous system disorders (Medical necessity review may be performed for
MS DRGs 056, 057 and 069 only.)

DRG validation-kidney and urinary tract disorders (Medical necessity review may be
performed for MS DRGs 682-684 and 689 only.)

DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be
performed for MS DRG 640 only.)

DRG validation-gastrointestinal disorders (Medical necessity review may be performed for
MS DRGs 391 and 393 only.)

DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG
249 only.)
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS
DRGs 190, 191 and 192 only.)

DRG validation-cardiovascular procedures (253 and 254 only)
North Dakota
Region D/HDI
For Part A claims:
 SNF Consolidated Billing
 Hospice Related Services – B
 Acute Hospital Readmissions without condition code B4 or 42
 Incorrect patient status-IRF
 Minor surgery and other treatment billed as an inpatient stay
 Acute inpatient hospitalization – infections
 Acute inpatient hospitalization - musculoskeletal disorders
 Acute inpatient hospitalization - respiratory conditions
 Acute inpatient hospitalization - neurological disorders
 Gastrointestinal disorders billed as an inpatient stay
 Nervous system disorders billed as an inpatient stay
 Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
 OP services within 72 hours of admit
 Neulasta (HCPCS code J2505)
 Medically unlikely edits
For Part B claims:
 Global vs. TC/PC
 Facility vs. Non-Facility Reimbursement (Inpatient)
 NCCI Edits
 Hospice Related Services – B
 TC of Radiology
 Not a New Patient

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











Medically unlikely edits
CSW During Inpatient
Ambulance during inpatient
Ambulance SNF to SNF transfer (NN Modifier)
Date of death
Part B duplicates - automated review
Co-surgery not billed with modifier 62
Global days
Anesthesia care package E/M services
Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
Procedures performed during the global period of other procedures
Multiple surgery reduction errors: single line modifier 51 underpayments
Multiple surgery reduction errors - underpayments
Multiple surgery reduction errors – overpayments
Wheelchair seating, mutually exclusive codes
AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
 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
For inpatient hospital claims:
 Inpatient admissions without a physician's inpatient admit order
For DME 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
 Complex review of lower limb prosthetics
 Therapeutic footwear utilization
 Mobility durable medical equipment paid after claim patient lift paid
 Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD)
accessories
 Overutilization of nebulizer medications
 Lower limb suction valve prosthetics
 Breast prosthetics allowed one a side
 Transcutaneous electrical nerve stimulators (TENS) supplies bundling
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)
 Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263,
264)
 Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
 Eye procedures (MS-DRGs 113-117)
 Female reproductive system procedures (MS-DRGs 734-750)
 Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)

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 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)

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 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)
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



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
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)
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)
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)
Incorrect patient status-acute
For medical necessity DRG validation claims:

DRG validation-cardiovascular, other (Medical necessity review may be performed for MS
DRG 312 only)

DRG validation-musculoskeletal disorders (Medical necessity review may be performed for
MS DRGs 551 and 552 only.)

DRG validation-blood and immunological disorders (Medical necessity review may be
performed for MS DRG 811 only.)

DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS
DRGs 253, 254, 291-293, 302, 308, 313-316 only.)

DRG validation-nervous system disorders (Medical necessity review may be performed for
MS DRGs 056, 057 and 069 only.)

DRG validation-kidney and urinary tract disorders (Medical necessity review may be
performed for MS DRGs 682-684 and 689 only.)

DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be
performed for MS DRG 640 only.)

DRG validation-gastrointestinal disorders (Medical necessity review may be performed for
MS DRGs 391 and 393 only.)

DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG
249 only.)
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS
DRGs 190, 191 and 192 only.)

DRG validation-cardiovascular procedures (253 and 254 only)
Nebraska
Region D/HDI
For Part A claims:
 SNF Consolidated Billing
 Hospice Related Services – B
 Acute Hospital Readmissions without condition code B4 or 42
 Incorrect patient status-IRF
 Minor surgery and other treatment billed as an inpatient stay
 Acute inpatient hospitalization – infections
 Acute inpatient hospitalization - musculoskeletal disorders
 Acute inpatient hospitalization - respiratory conditions
 Acute inpatient hospitalization - neurological disorders
 Gastrointestinal disorders billed as an inpatient stay
 Nervous system disorders billed as an inpatient stay
 Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
 OP services within 72 hours of admit
 Neulasta (HCPCS code J2505)
 Medically unlikely edits
For Part B claims:
 Global vs. TC/PC
 Facility vs. Non-Facility Reimbursement (Inpatient)
 NCCI Edits
 Hospice Related Services – B
 TC of Radiology
 Not a New Patient
 Medically unlikely edits
 CSW During Inpatient
 Ambulance during inpatient
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

Ambulance SNF to SNF transfer (NN Modifier)
Date of death
Part B duplicates - automated review
Co-surgery not billed with modifier 62
Global days
Anesthesia care package E/M services
Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
Procedures performed during the global period of other procedures
Multiple surgery reduction errors: single line modifier 51 underpayments
Multiple surgery reduction errors - underpayments
Multiple surgery reduction errors – overpayments
Wheelchair seating, mutually exclusive codes
AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
 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
For inpatient hospital claims:
 Inpatient admissions without a physician's inpatient admit order
For DME 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
 Complex review of lower limb prosthetics
 Therapeutic footwear utilization
 Mobility durable medical equipment paid after claim patient lift paid
 Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD)
accessories
 Overutilization of nebulizer medications
 Lower limb suction valve prosthetics
 Breast prosthetics allowed one a side
 Transcutaneous electrical nerve stimulators (TENS) supplies bundling
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)
 Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263,
264)
 Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
 Eye procedures (MS-DRGs 113-117)
 Female reproductive system procedures (MS-DRGs 734-750)
 Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)

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 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)

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 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)

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









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)
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)
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)
Incorrect patient status-acute
For medical necessity DRG validation claims:

DRG validation-cardiovascular, other (Medical necessity review may be performed for MS
DRG 312 only)

DRG validation-musculoskeletal disorders (Medical necessity review may be performed for
MS DRGs 551 and 552 only.)

DRG validation-blood and immunological disorders (Medical necessity review may be
performed for MS DRG 811 only.)

DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS
DRGs 253, 254, 291-293, 302, 308, 313-316 only.)

DRG validation-nervous system disorders (Medical necessity review may be performed for
MS DRGs 056, 057 and 069 only.)

DRG validation-kidney and urinary tract disorders (Medical necessity review may be
performed for MS DRGs 682-684 and 689 only.)

DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be
performed for MS DRG 640 only.)

DRG validation-gastrointestinal disorders (Medical necessity review may be performed for
MS DRGs 391 and 393 only.)

DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG
249 only.)
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS
DRGs 190, 191 and 192 only.)

DRG validation-cardiovascular procedures (253 and 254 only)
Nevada
Region D/HDI
For Part A claims:
 SNF Consolidated Billing
 Hospice Related Services – B
 Acute Hospital Readmissions without condition code B4 or 42
 Incorrect patient status-IRF
 Minor surgery and other treatment billed as an inpatient stay
 Acute inpatient hospitalization – infections
 Acute inpatient hospitalization - musculoskeletal disorders
 Acute inpatient hospitalization - respiratory conditions
 Acute inpatient hospitalization - neurological disorders
 Gastrointestinal disorders billed as an inpatient stay
 Nervous system disorders billed as an inpatient stay
 Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
 OP services within 72 hours of admit
 Neulasta (HCPCS code J2505)
 Medically unlikely edits
For Part B claims:
 Global vs. TC/PC
 Facility vs. Non-Facility Reimbursement (Inpatient)
 NCCI Edits
 Hospice Related Services – B
 TC of Radiology
 Not a New Patient
 Medically unlikely edits
 CSW During Inpatient
 Ambulance during inpatient
 Ambulance SNF to SNF transfer (NN Modifier)
 Date of death
 Part B duplicates - automated review










Co-surgery not billed with modifier 62
Global days
Anesthesia care package E/M services
Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
Procedures performed during the global period of other procedures
Multiple surgery reduction errors: single line modifier 51 underpayments
Multiple surgery reduction errors - underpayments
Multiple surgery reduction errors – overpayments
Wheelchair seating, mutually exclusive codes
AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
 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
For inpatient hospital claims:
 Inpatient admissions without a physician's inpatient admit order
For DME 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
 Complex review of lower limb prosthetics
 Therapeutic footwear utilization
 Mobility durable medical equipment paid after claim patient lift paid
 Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD)
accessories
 Overutilization of nebulizer medications
 Lower limb suction valve prosthetics
 Breast prosthetics allowed one a side
 Transcutaneous electrical nerve stimulators (TENS) supplies bundling
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)
 Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263,
264)
 Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
 Eye procedures (MS-DRGs 113-117)
 Female reproductive system procedures (MS-DRGs 734-750)
 Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)

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 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)

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 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,

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

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





776, 777, 778, 779, 780, 781, 782
Breast Procedures (MSDRGS 582, 583, 584, 585, 600, 601)
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)
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)
Incorrect patient status-acute
For medical necessity DRG validation claims:

DRG validation-cardiovascular, other (Medical necessity review may be performed for MS
DRG 312 only)

DRG validation-musculoskeletal disorders (Medical necessity review may be performed for
MS DRGs 551 and 552 only.)

DRG validation-blood and immunological disorders (Medical necessity review may be
performed for MS DRG 811 only.)

DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS
DRGs 253, 254, 291-293, 302, 308, 313-316 only.)

DRG validation-nervous system disorders (Medical necessity review may be performed for
MS DRGs 056, 057 and 069 only.)

DRG validation-kidney and urinary tract disorders (Medical necessity review may be
performed for MS DRGs 682-684 and 689 only.)

DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be
performed for MS DRG 640 only.)

DRG validation-gastrointestinal disorders (Medical necessity review may be performed for
MS DRGs 391 and 393 only.)

DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG
249 only.)
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS
DRGs 190, 191 and 192 only.)

DRG validation-cardiovascular procedures (253 and 254 only)
Oregon
Region D/HDI
For Part A claims:
 SNF Consolidated Billing
 Hospice Related Services – B
 Acute Hospital Readmissions without condition code B4 or 42
 Incorrect patient status-IRF
 Minor surgery and other treatment billed as an inpatient stay
 Acute inpatient hospitalization – infections
 Acute inpatient hospitalization - musculoskeletal disorders
 Acute inpatient hospitalization - respiratory conditions
 Acute inpatient hospitalization - neurological disorders
 Gastrointestinal disorders billed as an inpatient stay
 Nervous system disorders billed as an inpatient stay
 Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
 OP services within 72 hours of admit
 Neulasta (HCPCS code J2505)
 Medically unlikely edits
For Part B claims:
 Global vs. TC/PC
 Facility vs. Non-Facility Reimbursement (Inpatient)
 NCCI Edits
 Hospice Related Services – B
 TC of Radiology
 Not a New Patient
 Medically unlikely edits
 CSW During Inpatient
 Ambulance during inpatient
 Ambulance SNF to SNF transfer (NN Modifier)
 Date of death
 Part B duplicates - automated review
 Co-surgery not billed with modifier 62
 Global days
 Anesthesia care package E/M services
 Practice expense (PE) relative value unit (RVU) increase for CPT code 93503






Procedures performed during the global period of other procedures
Multiple surgery reduction errors: single line modifier 51 underpayments
Multiple surgery reduction errors - underpayments
Multiple surgery reduction errors – overpayments
Wheelchair seating, mutually exclusive codes
AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
 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
For inpatient hospital claims:
 Inpatient admissions without a physician's inpatient admit order
For DME 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
 Complex review of lower limb prosthetics
 Therapeutic footwear utilization
 Mobility durable medical equipment paid after claim patient lift paid
 Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD)
accessories
 Overutilization of nebulizer medications
 Lower limb suction valve prosthetics
 Breast prosthetics allowed one a side
 Transcutaneous electrical nerve stimulators (TENS) supplies bundling
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)
 Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263,
264)

Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
 Eye procedures (MS-DRGs 113-117)
 Female reproductive system procedures (MS-DRGs 734-750)
 Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)

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 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)

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 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)
 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)
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)
Incorrect patient status-acute
For medical necessity DRG validation claims:

DRG validation-cardiovascular, other (Medical necessity review may be performed for MS
DRG 312 only)

DRG validation-musculoskeletal disorders (Medical necessity review may be performed for
MS DRGs 551 and 552 only.)

DRG validation-blood and immunological disorders (Medical necessity review may be
performed for MS DRG 811 only.)

DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS
DRGs 253, 254, 291-293, 302, 308, 313-316 only.)

DRG validation-nervous system disorders (Medical necessity review may be performed for
MS DRGs 056, 057 and 069 only.)

DRG validation-kidney and urinary tract disorders (Medical necessity review may be
performed for MS DRGs 682-684 and 689 only.)

DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be
performed for MS DRG 640 only.)

DRG validation-gastrointestinal disorders (Medical necessity review may be performed for
MS DRGs 391 and 393 only.)

DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG
249 only.)
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS
DRGs 190, 191 and 192 only.)

DRG validation-cardiovascular procedures (253 and 254 only)
South Dakota
Region D/HDI
For Part A claims:
 SNF Consolidated Billing
 Hospice Related Services – B
 Acute Hospital Readmissions without condition code B4 or 42
 Incorrect patient status-IRF
 Minor surgery and other treatment billed as an inpatient stay
 Acute inpatient hospitalization – infections
 Acute inpatient hospitalization - musculoskeletal disorders
 Acute inpatient hospitalization - respiratory conditions
 Acute inpatient hospitalization - neurological disorders
 Gastrointestinal disorders billed as an inpatient stay
 Nervous system disorders billed as an inpatient stay
 Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
 OP services within 72 hours of admit
 Neulasta (HCPCS code J2505)
 Medically unlikely edits
For Part B claims:
 Global vs. TC/PC
 Facility vs. Non-Facility Reimbursement (Inpatient)
 NCCI Edits
 Hospice Related Services – B
 TC of Radiology
 Not a New Patient
 Medically unlikely edits
 CSW During Inpatient
 Ambulance during inpatient
 Ambulance SNF to SNF transfer (NN Modifier)
 Date of death
 Part B duplicates - automated review
 Co-surgery not billed with modifier 62
 Global days
 Anesthesia care package E/M services
 Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
 Procedures performed during the global period of other procedures
 Multiple surgery reduction errors: single line modifier 51 underpayments
 Multiple surgery reduction errors - underpayments
 Multiple surgery reduction errors – overpayments
 Wheelchair seating, mutually exclusive codes
 AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
 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
For DME 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
 Therapeutic footwear utilization
 Mobility durable medical equipment paid after claim patient lift paid
 Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD)
accessories
 Overutilization of nebulizer medications
 Lower limb suction valve prosthetics
 Breast prosthetics allowed one a side
 Transcutaneous electrical nerve stimulators (TENS) supplies bundling
For inpatient hospital claims:
 Inpatient admissions without a physician's inpatient admit order
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)
 Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263,
264)

Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
 Eye procedures (MS-DRGs 113-117)
 Female reproductive system procedures (MS-DRGs 734-750)
 Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)

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 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)

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 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)
 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)
 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)
Incorrect patient status-acute
For medical necessity DRG validation claims:

DRG validation-cardiovascular, other (Medical necessity review may be performed for MS
DRG 312 only)

DRG validation-musculoskeletal disorders (Medical necessity review may be performed for
MS DRGs 551 and 552 only.)

DRG validation-blood and immunological disorders (Medical necessity review may be
performed for MS DRG 811 only.)

DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS
DRGs 253, 254, 291-293, 302, 308, 313-316 only.)

DRG validation-nervous system disorders (Medical necessity review may be performed for
MS DRGs 056, 057 and 069 only.)

DRG validation-kidney and urinary tract disorders (Medical necessity review may be
performed for MS DRGs 682-684 and 689 only.)

DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be
performed for MS DRG 640 only.)

DRG validation-gastrointestinal disorders (Medical necessity review may be performed for
MS DRGs 391 and 393 only.)

DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG
249 only.)
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS
DRGs 190, 191 and 192 only.)

DRG validation-cardiovascular procedures (253 and 254 only)
Utah
Region D/HDI
For Part A claims:
 SNF Consolidated Billing
 Hospice Related Services – B
 Acute Hospital Readmissions without condition code B4 or 42
 Incorrect patient status-IRF
 Minor surgery and other treatment billed as an inpatient stay
 Acute inpatient hospitalization – infections
 Acute inpatient hospitalization - musculoskeletal disorders
 Acute inpatient hospitalization - respiratory conditions
 Acute inpatient hospitalization - neurological disorders
 Gastrointestinal disorders billed as an inpatient stay
 Nervous system disorders billed as an inpatient stay
 Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
 OP services within 72 hours of admit
 Neulasta (HCPCS code J2505)
 Medically unlikely edits
For Part B claims:
 Global vs. TC/PC
 Facility vs. Non-Facility Reimbursement (Inpatient)
 NCCI Edits
 Hospice Related Services – B
 TC of Radiology
 Not a New Patient
 Medically unlikely edits
 CSW During Inpatient
 Ambulance during inpatient
 Ambulance SNF to SNF transfer (NN Modifier)
 Date of death
 Part B duplicates - automated review
 Co-surgery not billed with modifier 62
 Global days
 Anesthesia care package E/M services
 Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
 Procedures performed during the global period of other procedures
 Multiple surgery reduction errors: single line modifier 51 underpayments
 Multiple surgery reduction errors - underpayments
 Multiple surgery reduction errors – overpayments
 Wheelchair seating, mutually exclusive codes
 AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
 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
For inpatient hospital claims:
 Inpatient admissions without a physician's inpatient admit order
For DME 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
 Complex review of lower limb prosthetics
 Therapeutic footwear utilization
 Mobility durable medical equipment paid after claim patient lift paid
 Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD)
accessories
 Overutilization of nebulizer medications
 Lower limb suction valve prosthetics
 Breast prosthetics allowed one a side
 Transcutaneous electrical nerve stimulators (TENS) supplies bundling
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)
 Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263,
264)

Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
 Eye procedures (MS-DRGs 113-117)
 Female reproductive system procedures (MS-DRGs 734-750)
 Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)

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 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)
 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 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)
 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)
 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)
 Incorrect patient status-acute
For medical necessity DRG validation claims:

DRG validation-cardiovascular, other (Medical necessity review may be performed for MS
DRG 312 only)

DRG validation-musculoskeletal disorders (Medical necessity review may be performed for
MS DRGs 551 and 552 only.)

DRG validation-blood and immunological disorders (Medical necessity review may be
performed for MS DRG 811 only.)

DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS
DRGs 253, 254, 291-293, 302, 308, 313-316 only.)

DRG validation-nervous system disorders (Medical necessity review may be performed for
MS DRGs 056, 057 and 069 only.)

DRG validation-kidney and urinary tract disorders (Medical necessity review may be
performed for MS DRGs 682-684 and 689 only.)

DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be
performed for MS DRG 640 only.)

DRG validation-gastrointestinal disorders (Medical necessity review may be performed for
MS DRGs 391 and 393 only.)

DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG
249 only.)
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS
DRGs 190, 191 and 192 only.)

DRG validation-cardiovascular procedures (253 and 254 only)
Washington
Region D/HDI
For Part A claims:
 SNF Consolidated Billing
 Hospice Related Services – B
 Acute Hospital Readmissions without condition code B4 or 42
 Incorrect patient status-IRF
 Minor surgery and other treatment billed as an inpatient stay
 Acute inpatient hospitalization – infections
 Acute inpatient hospitalization - musculoskeletal disorders
 Acute inpatient hospitalization - respiratory conditions
 Acute inpatient hospitalization - neurological disorders
 Gastrointestinal disorders billed as an inpatient stay
 Nervous system disorders billed as an inpatient stay
 Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
 OP services within 72 hours of admit
 Neulasta (HCPCS code J2505)
 Medically unlikely edits
For Part B claims:
 Global vs. TC/PC
 Facility vs. Non-Facility Reimbursement (Inpatient)
 NCCI Edits
 Hospice Related Services – B
 TC of Radiology
 Not a New Patient
 Medically unlikely edits
 CSW During Inpatient
 Ambulance during inpatient
 Ambulance SNF to SNF transfer (NN Modifier)
 Date of death
 Part B duplicates - automated review
 Co-surgery not billed with modifier 62
 Global days
 Anesthesia care package E/M services
 Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
 Procedures performed during the global period of other procedures
 Multiple surgery reduction errors: single line modifier 51 underpayments
 Multiple surgery reduction errors - underpayments
 Multiple surgery reduction errors – overpayments
 Wheelchair seating, mutually exclusive codes
 AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
 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
For inpatient hospital claims:
 Inpatient admissions without a physician's inpatient admit order
For DME 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
 Complex review of lower limb prosthetics
 Therapeutic footwear utilization
 Mobility durable medical equipment paid after claim patient lift paid
 Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD)
accessories
 Overutilization of nebulizer medications
 Lower limb suction valve prosthetics
 Breast prosthetics allowed one a side
 Transcutaneous electrical nerve stimulators (TENS) supplies bundling
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)
 Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263,
264)

Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
 Eye procedures (MS-DRGs 113-117)
 Female reproductive system procedures (MS-DRGs 734-750)
 Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)

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 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)

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 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)
 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)
 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)
 Incorrect patient status-acute
For medical necessity DRG validation claims:

DRG validation-cardiovascular, other (Medical necessity review may be performed for MS
DRG 312 only)

DRG validation-musculoskeletal disorders (Medical necessity review may be performed for
MS DRGs 551 and 552 only.)

DRG validation-blood and immunological disorders (Medical necessity review may be
performed for MS DRG 811 only.)

DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS
DRGs 253, 254, 291-293, 302, 308, 313-316 only.)

DRG validation-nervous system disorders (Medical necessity review may be performed for
MS DRGs 056, 057 and 069 only.)

DRG validation-kidney and urinary tract disorders (Medical necessity review may be
performed for MS DRGs 682-684 and 689 only.)

DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be
performed for MS DRG 640 only.)

DRG validation-gastrointestinal disorders (Medical necessity review may be performed for
MS DRGs 391 and 393 only.)

DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG
249 only.)
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS
DRGs 190, 191 and 192 only.)

DRG validation-cardiovascular procedures (253 and 254 only)
Wyoming
Region D/HDI
For Part A claims:
 SNF Consolidated Billing
 Hospice Related Services – B
 Acute Hospital Readmissions without condition code B4 or 42
 Incorrect patient status-IRF
 Minor surgery and other treatment billed as an inpatient stay
 Acute inpatient hospitalization – infections
 Acute inpatient hospitalization - musculoskeletal disorders
 Acute inpatient hospitalization - respiratory conditions
 Acute inpatient hospitalization - neurological disorders
 Gastrointestinal disorders billed as an inpatient stay
 Nervous system disorders billed as an inpatient stay
 Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
 OP services within 72 hours of admit
 Neulasta (HCPCS code J2505)
 Medically unlikely edits
For Part B claims:
 Global vs. TC/PC
 Facility vs. Non-Facility Reimbursement (Inpatient)
 NCCI Edits
 Hospice Related Services – B
 TC of Radiology
 Not a New Patient
 Medically unlikely edits
 CSW During Inpatient
 Ambulance during inpatient
 Ambulance SNF to SNF transfer (NN Modifier)
 Date of death
 Part B duplicates - automated review
 Co-surgery not billed with modifier 62
 Global days
 Anesthesia care package E/M services
 Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
 Procedures performed during the global period of other procedures
 Multiple surgery reduction errors: single line modifier 51 underpayments
 Multiple surgery reduction errors - underpayments
 Multiple surgery reduction errors – overpayments
 Wheelchair seating, mutually exclusive codes
 AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
 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
For inpatient hospital claims:
 Inpatient admissions without a physician's inpatient admit order
For DME claims:
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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
Complex review of lower limb prosthetics
Therapeutic footwear utilization
Mobility durable medical equipment paid after claim patient lift paid
Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD)
accessories
Overutilization of nebulizer medications
Lower limb suction valve prosthetics
Breast prosthetics allowed one a side
Transcutaneous electrical nerve stimulators (TENS) supplies bundling
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)
 Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263,
264)

Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
 Eye procedures (MS-DRGs 113-117)
 Female reproductive system procedures (MS-DRGs 734-750)
 Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)
 Health status factors (MS-DRGs 939, 940, 941, 945-951)
 Infection (MS-DRGs 094, 095, 096, 853, 854, 855, 867, 868, 869)
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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)
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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 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)
 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)
 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)
 Incorrect patient status-acute
For medical necessity DRG validation claims:
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DRG validation-cardiovascular, other (Medical necessity review may be performed for MS
DRG 312 only)
DRG validation-musculoskeletal disorders (Medical necessity review may be performed for
MS DRGs 551 and 552 only.)
DRG validation-blood and immunological disorders (Medical necessity review may be
performed for MS DRG 811 only.)

DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS
DRGs 253, 254, 291-293, 302, 308, 313-316 only.)

DRG validation-nervous system disorders (Medical necessity review may be performed for
MS DRGs 056, 057 and 069 only.)

DRG validation-kidney and urinary tract disorders (Medical necessity review may be
performed for MS DRGs 682-684 and 689 only.)

DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be
performed for MS DRG 640 only.)

DRG validation-gastrointestinal disorders (Medical necessity review may be performed for
MS DRGs 391 and 393 only.)

DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG
249 only.)
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS
DRGs 190, 191 and 192 only.)

DRG validation-cardiovascular procedures (253 and 254 only)
