Special Review Considerations

6.5.5 – Special Review Considerations (Rev. 608, Issued: 08-14-15, Effective: 01-01-12, Implementation: 09-14-15) Refer to Pub. 100-04, chapter 3, §20 C. for information regarding handling of claims with DRG 468. This DRG represents a discharge with valid data but where the surgical procedure is unrelated to the principal diagnosis. Refer to 100-04, chapter 3, §20.2.1, subsection D.9. for a description of questionable admission diagnosis codes. A/B MACs (A) may wish to consider including these diagnoses in their data analysis. For a listing of diagnosis codes identified as “questionable admission” codes see the Medicare Code Editor (MCE) Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/AcuteInpatientPPS/index.html?redirect=/AcuteInpatientPPS/01_overview.asp Refer to 100-04, chapter 3, §20.2.1, subsection D.9 for a description of diagnoses which are acceptable only when coded with a secondary diagnosis. A/B MACs (A) may wish to include these diagnoses in their data analysis as the MCE will not reject them when they are billed with a secondary diagnosis. For a listing of diagnosis codes that are acceptable only when coded with a secondary diagnosis see the MCE Website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/AcuteInpatientPPS/Downloads/FY_14_Definition_of- Medicare_Code_Edits_V_31_Manual.pdf