Review of Procedures Affecting the DRG

6.5.4 – Review of Procedures Affecting the DRG (Rev. 475, Issued: 07-19-13, Effective Date: 08-19-13; Implementation Date: 08-19- 13) The contractor shall determine whether the performance of any procedure that affects, or has the potential to affect, the DRG was reasonable and medically necessary. If the admission and the procedure were medically necessary, but the procedure could have been performed on an outpatient basis if the beneficiary had not already been in the hospital, do not deny the procedure or the admission. When a procedure was not medically necessary, the contractor shall follow these guidelines: If the admission was for the sole purpose of the performance of the non-covered procedure, and the beneficiary never developed the need for a covered level of service, deny the admission; If the admission was appropriate, and not for the sole purpose of performing the procedure, deny the procedure (i.e., remove from the DRG calculation), but approve the admission; If performing a cost outlier review, in accordance with Pub. 100-10, chapter 4, §4210 B, and the beneficiary was in the hospital for any day(s) solely for the performance of the procedure or care related to the procedure, deny the costs for the day(s) and for the performance of the procedure; and If performing a cost outlier review, and the beneficiary was receiving the appropriate level of covered care for all hospital days, deny the procedure or service. See Pub. 100-02, Chapter 1, §10 for further detail on payment of inpatient claims containing non-covered services.