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Elizabeth M. Whitehorn, Director

Provider Notice issued 06/25/04

 

Additional DRG Codes Subject to Prepayment Review

To:​

Enrolled Hospitals: Chief Executive Officers, Chief Financial Officers, Patient Accounts Managers and Health Information Management Directors​
Date:​ June 25, 2004​
Re:​

Additional DRG Codes Subject to Prepayment Review ​

 

 

Effective with inpatient admissions on and after August 1, 2004, claims that group to DRG 386 or DRG 986 (both defined as Extreme Immaturity or Respiratory Distress Syndrome) may be subject to prepayment review of the medical record by HealthSystems of Illinois (HSI), the department’s contracted Peer Review Organization (PRO). As with other prepayment review, the PRO will verify the medical necessity of the inpatient stay, validate the diagnosis and procedure codes billed and evaluate the quality of care provided.

 

On the reverse side of this page is an updated listing of the DRG codes subject to prepayment review for all hospitals. A description of the PRO review and reconsideration processes can be found on the PRO’s Web site.

 

Any questions regarding this notice may be directed to the Bureau of Contract Management at 217-524-7478.

 

Anne Marie Murphy, Ph.D.

Administrator

Division of Medical Programs

DRG
DESCRIPTION
   

386*

Extreme Immaturity or Respiratory Distress Syndrome

986*

Extreme Immaturity or Respiratory Distress Syndrome

468

Extensive OR Procedure Unrelated to Principal Diagnosis

477

Non-Extensive OR Procedure Unrelated to Principal Diagnosis

025

Seizure & Headache, Age > 17 years, Without Complications and Comorbidities

098

Bronchitis and Asthma, Age 0-17 years

134

Hypertension

143

Chest Pain

182

Esophagitis, Gastroenteritis, & Miscellaneous Digestive Disorders, Age > 17 years, With Complications and Comorbidities

183

Esophagitis, Gastroenteritis, & Miscellaneous Digestive Disorders, Age > 17 years, Without Complications and Comorbidities

184

Esophagitis, Gastroenteritis, & Miscellaneous Digestive Disorders, Age 0-17 years

243

Medical Back Problems

369

Menstrual and Other Female Reproductive System Disorders

381

Abortion with Dilation and Curettage, Aspiration Curettage or Hysterotomy

410

Chemotherapy Without Acute Leukemia as Secondary Diagnosis

435

Alcohol/Drug Abuse or Dependence, Detoxification or Other Symptomatic Treatment, Without Complications and Comorbidities

 

* Code Added Effective 08/01/04

 

Attachment to DRG Codes Subject to Prepayment Review notice.