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New Issues Approved by CMS

All new issues that are identified by HDI must first be approved by CMS.

Number of Records per Page
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NameDescriptionNumberProvider TypeDate ApprovedRegion D StatesRegion D MACSDates of ServiceAdditional Information
Acute Inpatient Hospitalization - Bowel and Rectal Procedures (DRG 329, 330, 332, 333, 334, 344, 345 and 346)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D000022012Acute Care02/10/2012All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
Acute Inpatient Hospitalization - Hepatobiliary Procedures (DRG 420, 421, 422, 424 and 425)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D000202012Acute Care02/10/2012All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
E/M Billed Without Modifier 25 on Same Day as DialysisExcept when reported with modifier 25, payment for certain evaluation and management services is bundled into the payment for dialysis services 90935, 90937, 90945, and 90947.D004372011Physician02/10/2012All Region D StatesAB MACs; CarrierClaims that have a “claim paid date” which is less than 3 years prior to the Demand Letter date.Medicare Claims Processing Manual: Publication 100-04; Chapter 8, § 170 (B)
Acute Inpatient Hospitalization - Abdominal Procedures (DRG - 326, 335, 405, 406, 799, 800 and 801)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D000032012Acute Care01/29/2012All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
Acute Inpatient Hospitalization - Spinal Procedures (DRG 028, 029, 030, 453, 454, 455 and 491)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D000042012Acute Care01/29/2012All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
SNF Consolidated Billing for Therapies During a Part B SNF StayFor Medicare beneficiaries in a SNF Part B stay, therapies are subject to SNF consolidated billing. Outpatient physical therapy, outpatient speech-language pathology services, and outpatient occupational therapy are billable services by the SNF even when another entity renders the services under arrangement with the SNF.D003472011Physician01/28/2012All Region D StatesAB MACs; CarrierClaims that have a “claim paid date” which is less than 3 years prior to the Demand Letter date.1) Medicare Claims Processing Manual: CMS Pub 100-04; Chapter 7 § 10.1, 40 and 110. 2) Overview on Skilled Nursing Facility (SNF) Consolidated Billing (CB) 3) Carrier File Explanation SNF Consolidated Billing
Acute Inpatient Hospitalization - Lower Extremity and Humerus Procedures except Hip, Foot, Femur without CC/MCC (DRG 494)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D004172011Acute Care12/22/2011All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
Acute Inpatient Hospitalization - Lower Extremity and Humerus Procedures except Hip, Foot, Femur with CC (DRG 493)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D004162011Acute Care12/22/2011All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
Acute Inpatient Hospitalization - Major Joint and Limb Reattachment Procedures of Upper Extremity without CC/MCC (DRG 484)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D004152011Acute Care12/22/2011All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
Acute Inpatient Hospitalization - Major Shoulder or Elbow Joint Procedures without CC/MCC (DRG 508)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D004182011Acute Care12/22/2011All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
Acute Inpatient Hospitalization - Uterine and Adnexa Procedures for Non0Ovarian/Non-Adnexal Malignancy with CC/MCC (DRG 741)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D004212011Acute Care12/22/2011All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
Acute Inpatient Hospitalization - Other Endocrine, Nutritional and Metabolic OR Procedures with CC (DRG 629)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D004202011Acute Care12/22/2011All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
Acute Inpatient Hospitalization - Other Endocrine, Nutritinoal and Metabolic OR Procedures with MCC (DRG 628)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D004192011Acute Care12/22/2011All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
Acute Inpatient Hospitalization - Amputation for Musculoskeletal System and Connective Tissue dis without CC/MCC (DRG 476)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D004142011Acute Care12/22/2011All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
Acute Inpatient Hospitalization - Stomach, Esophageal and Duodenal Procedures without CC/MCC (DRG 328)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D004092011Acute Care12/22/2011All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
Acute Inpatient Hospitalization - Stomach, Esophageal and Doudenal Procedures with CC (DRG 327)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D004082011Acute Care12/22/2011All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
Acute Inpatient Hospitalization - Other Respiratory System OR Procedures without CC/MCC (DRG 168)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D004072011Acute Care12/22/2011All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
Acute Inpatient Hospitalization - Major Small and Large Bowel Procedures without CC/MCC (DRG 331)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D004102011Acute Care12/22/2011All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
Acute Inpatient Hospitalization - Pancreas, Liver and Shunt Procedures without CC/MCC (DRG 407)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D004132011Acute Care12/22/2011All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
Acute Inpatient Hospitalization - Peritoneal Adhesiolysis without CC/MCC (DRG 337)Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.D004122011Acute Care12/22/2011All Region D States and TerritoriesPart A MACClaims having a claim paid date within three years of the ADR dateCMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 1, Section 10 CMS Publication 100-02 Medicare Benefit Policy Manual: Chapter 6, Section 10 CMS Publication 100-08 Medicare Program Integrity Manual: Chapter 6, Section 6.5.2
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