Agencies
Services
Provider Notice issued 05/01/08
Attachment C Utilization Review Update for June 1, 2008
| To: |
Participating Hospitals – Chief Executive Officers, Chief Financial Officers, Patient Accounts Managers, and Utilization Review Departments |
| Date: | May 1, 2008 |
| Re: |
Attachment C Utilization Review Update for June 1, 2008 |
This informational notice provides notification of changes to diagnosis codes subject to admission/concurrent inpatient utilization review, and contains a reminder of the department’s policy regarding 4th and 5th digit codes subject to utilization review activities.
Changes in Diagnosis Codes on Attachment C
Effective with admissions on and after June 1, 2008, diagnosis codes 282.62, 402.XX, 404.XX, 413.XX, 492.XX, 810.00 and 825.25 are eliminated from Attachment C.
Effective with admissions on and after June 1, 2008, the following diagnosis codes are subject to mandatory concurrent review and have been added to Attachment C:
038.0 |
Streptococcal septicemia |
038.10 |
Staphylococcal septicemia, unspecified |
038.11 |
Staphylococcus aureus septicemia |
038.19 |
Other staphylococcal septicemia |
038.2 |
Pneumococcal septicemia |
038.3 |
Septicemia due to anaerobes |
038.40 |
Septicemia due to gram-negative organism, unspecified |
038.41 |
Septicemia due to hemophilus influenzae (H.influenzae) |
038.43 |
Septicemia due to Pseudomonas |
038.44 |
Septicemia due to Serratia |
276.1 |
Hyposmolality and/or hyponatremia |
276.7 |
Hyperpotassemia |
276.8 |
Hypopotassemia |
491.20 |
Obstructive Chronic bronchitis without acute exacerbation |
707.11 |
Ulcer of thigh, except decubitus |
707.12 |
Ulcer of calf, except decubitus |
707.14 |
Ulcer of heel and midfoot |
707.8 |
Chronic skin ulcer of other specified sites |
789.51 |
Malignant Ascites |
789.59 |
Other Ascites |
The following codes are deleted from Attachment C, as the codes require a 4th or 5th digit for billing:
276.5 |
Disorders of fluid, electrolyte, and acid balance, volume depletion |
585 |
Chronic kidney disease |
There are no changes at this time to Attachments A, B and D. All of the attachments can be downloaded from the department’s Web site at: <http://www.illinois.gov/hfs/MedicalProviders/proqio/Pages/default.aspx>.
4th and 5th Digit Diagnosis Codes
Attachments A and B: Any admitting diagnosis code with the same root diagnosis code on Attachments A and B that requires a 4th or 5th digit extension is subject to review. Therefore, as long as the hospitalization was reviewed, even if the 4th or 5th digit extension reported on the claim differs from the one provided during an admission review request, the claim will not be rejected for failure to obtain certification.
Attachment C: Only selected admitting diagnosis codes that require the 4th or 5th digit review are subject to review. The hospital should provide the admitting diagnosis code at the time of the concurrent review request.
When a diagnosis code is subject to review and ICD-9-CM coding guidelines mandate a coding change requiring a 4th or 5th digit code extension, the 4th and 5th digit code extension will automatically be subject to review. As first stated in a HFS Informational Notice dated December 1, 2004, HFS will not send a notice to providers identifying this type of coding change. Department notices are available at:
<http://www.illinois.gov/hfs/MedicalProviders/notices/Pages/default.aspx>.
Any questions regarding the review process may be directed to HealthSystems of Illinois (HSI) at the toll-free Helpline at 800-418-4045. Any questions regarding this notice may be directed to the Bureau of Healthcare Quality Improvement at 217-557-1000.
Theresa A. Eagleson, Administrator
Division of Medical Programs