When the newsletter covers the issue of "inpatient hospital services—heart failure and shock (DRG 127) criteria for inpatient care not met," she says. Which is the same issue as the pacemaker cases being not medically necessary—they don't mention condition code 44. Instead they focus on sections of the Program Integrity Manual related to documentation, Hoy adds.
"It seems that CMS is looking at these situations differently even though they are both issues of medical necessity of inpatient care because they reference condition code 44 in the pacemaker section, whereas the heart failure and shock section seems to focus on documentation." Hoy says.
Potentially confusing guidance aside, there is certainly something to be learned from this issue, and from future editions. In this initial release, for example, CMS suggests that providers review Chapter 6, section 6.5 of the Program Integrity Manual,where you can find all the standards for medical review, and is something hospitals should definitely review because it has been amended over the last year, according to Hoy.