Palmetto Posts a Series of DRG Education Articles

on Tuesday, 25 June 2019. All News Items | Medicare Coverage | Documentation | CERT

A Smorgasbord of Education

My first thought when I hear the word “smorgasbord,” in keeping with its primary definition, is a large well-stocked buffet meal. Can’t you just see and smell the seafood, soups, salad bars, meats, vegetables, side dishes and of course, desserts? It is hard to know where to begin and when to stop. The word “smorgasbord” has also come to mean any extensive array or variety. Recently, Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, has published a smorgasbord of articles about various DRGs. These articles can be found under General Information on the CERT Topics webpage on either JJ Part A CERT General Information or JM Part A CERT General Information.

As a reminder, CERT, which stands for Comprehensive Error Rate Testing (program), was established by CMS to monitor and report the accuracy of Medicare fee-for-service (FFS) payments. CERT contractors select random claims out of the total claims’ submissions for a contractor for review. This random review of claims differs from that of other Medicare review entities who review selected topics based on risk and data analysis of aberrant utilization and/or billing patterns. A random review results in lower error rates since high-risk areas are not targeted, but it is also able to identify a broader array of issues.

CERT findings are used by other Medicare contractors, especially the MACs, to select topics for targeted reviews. According to Palmetto’s CERT webpage, “The CERT program measures the error rate for claims submitted to Medicare contractors. Palmetto GBA uses CERT reports to identify areas of focus for our Provider Outreach & Education efforts. One of the major outcomes of these CERT reports is the paid claims error rate (percentage of dollars paid incorrectly).” This means the CERT is sort of a report card on the MACs and in order to make a better “grade” the MACs educate providers based on the errors identified by the CERT. This can be accomplished through targeted reviews as mentioned above or through educational articles such as those that are the topic of this article.

The Palmetto articles offer a variety of information from documentation requirements to information on assignment of principal and secondary diagnosis to coverage requirements to consideration of an alternate DRG. Below is a listing of the DRGs featured in a Palmetto article so far, at the time of the writing of this article. It is possible Palmetto may be adding other articles, so check the links above to watch for more articles.

DRG 266 - Endovascular Cardiac Valve Replacement with MCC

  • Addresses Transcatheter Aortic Valve Replacement (TAVR) and Tricuspid Valve Replacement
  • Provides requirements for and a listing of ICD-10-PCS procedure codes
  • “The correct procedure code must depict: Initial placement, Replacement, Removal, or Adjustment”
  • TPE review topic for Jurisdiction N MAC, First Coast.

DRG 460 – Spinal Fusion

  • Provides documentation requirements and strategies to support payment for spinal fusion-related hospital care, to reduce audit errors, and to substantiate the medical necessity of the procedure for a particular patient
  • “The most common reason for denial has been a lack of specific information about conservative care before the surgical intervention. Statements such as: “Failed outpatient therapy, admit for spinal fusion” are simply not sufficient evidence of medical necessity for the admission or the surgery.”
  • Palmetto recently released a new LCD for Spinal Fusion services.
  • TPE review topic for CGS, J15; new 2019 topic for Supplemental Medical Review Contractor (SMRC); and PEPPER target.

DRG 193, 194, and 195 - Simple Pneumonia and Pleurisy

  • Addresses appropriate assignment of the principal and secondary diagnoses
  • “Abnormal billing practices are seen when the principle and secondary diagnoses are improperly assigned, which can result in overpayments. The most common areas were related to sequencing of the principal diagnosis and improper coding of secondary diagnosis. Secondary diagnoses errors are related to selecting the improper code based on physician documentation or the addition of a secondary diagnosis that was not documented within the medical record.”
  • DRGs 193 and 194 are PEPPER targets.

DRG 313 – Chest Pain

  • Includes a listing of the principal diagnoses, a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
  • “The Principal Diagnoses are:
    • R072 Precordial pain
    • R0782 Intercostal pain
    • R0789 Other chest pain
    • R079 Chest pain, unspecified”
  • Palmetto has an LCD that addresses Chest Pain

DRG 884 – Organic Disturbances and Mental Retardation and DRG 885 - Psychoses

  • Provides information on coverage/benefits and documentation/billing requirements including the most common errors and reasons for denials
  • The most common CERT errors are insufficient documentation and medically unnecessary service or treatment
  • DRG 885 is currently a topic of review for both Palmetto JJ and JM Targeted Probe and Educate (TPE) program

DRG 092: Other Disorders of Nervous System with Complication or Comorbidity (CC) 

  • Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.

DRG 493 – Lower Extremity and Humerus Procedures except Hip, Foot, Femur w/CC)

  • Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
  • Also addresses medical record documentation requirements such as H&P, evidence of prior conservation treatment, outpatient records supporting medical necessity of procedure, imaging reports and operative reports.

DRG 682 - Renal Failure with Major Complication or Comorbidity (MCC)

  • Contains a listing of the documentation required to support the principal and secondary diagnoses.
  • This includes signs and symptoms, elevated urine protein, documented treatment, potential underlying cause, and specificity of whether acute or chronic failure
  • Palmetto recently added this DRG as a TPE review topic for both JJ and JM

DRG 057 – Degenerative Nervous System Disorders W/O MCC

  • Describes situations that can cause a neuropathic condition
  • “The most common medical condition to cause peripheral neuropathy is diabetes mellitus. … Other medical conditions, such as HIV, kidney disorders, hormonal imbalances and cancers may also damage nerve cells. Heredity can play a role, as can traumatic situations such as a crush injury or fractured bone, which can result in compression, stretching, or severing of the nerve cell, leading to a neuropathic condition.”
  • Also includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.

DRG 227 – Cardiac Defibrillator Implant W/O Cardiac Catheterization w/o MCC

  • Reviews the covered indications for implantation of a cardiac defibrillator
  • “Medicare defines the requirements for coverage of an implantable cardioverter-defibrillator (ICD) insertion in National Coverage Determination (NCD) 20.4, Implantable Automatic Defibrillators.”
  • All MACs have a coverage article that addresses “Implantable Automatic Defibrillators – Coding and Billing” which can be found on the Medicare Coverage Database or your MAC’s website.

DRG 518 (Back and Neck Procedures except Spinal Fusion w/ Major Complications or Comorbidity (MCC) or Disc Device or Neurostimulator)

  • Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.

DRG 312 – Syncope and Collapse

  • Addresses the causes and clinical considerations of syncope, process and approach of key components, and principal diagnosis.
  • Clinical considerations include other DRGs that might be more appropriate if the cause and underlying conditions can be determined.
  • Consideration of appropriate patient status - “People suspected of having cardiac syncope but who don't have serious medical conditions may be managed as outpatients. Further inpatient evaluation is needed if serious medical conditions are present.”
  • PEPPER target

DRG 517 (Other Musculoskeletal System and Connective Tissue O.R. Procedures without CC/MCC

  • Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
  • Also includes top ICD diagnosis codes, top ICD procedure code, and Charge Capture Analysis

DRG 556 (Signs and Symptoms of Musculoskeletal System and Connective Tissue without CC/MCC

  • Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
  • Also includes top ICD diagnosis codes, top ICD procedure code, and Charge Capture Analysis
  • “Do not use this DRG if the signs and symptoms are attributable to a specific condition:
    • DRG 542 — Fatigue, stress or pathological fracture, initial encounter
    • DRG 557 — Tendonitis, Myositis and Bursitis with MCC”

A smorgasbord indeed – lots to choose from and lots to digest. Happy reading!

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc.  Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system.  In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.  You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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