[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR478.15]



[Page 477]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 478_RECONSIDERATIONS AND APPEALS--Table of Contents

 

     Subpart B_Utilization and Quality Control Quality Improvement 

             Organization (QIO) Reconsiderations and Appeals

 

Sec.  478.15  QIO review of changes resulting from DRG validation.



    (a) General rules. (1) A provider or practitioner dissatisfied with 

a change to the diagnostic or procedural coding information made by a 

QIO as a result of DRG validation under section 1866(a)(1)(F) of the Act 

is entitled to a review of that change if--

    (i) The change caused an assignment of a different DRG; and

    (ii) Resulted in a lower payment.

    (2) A beneficiary may obtain a review of a QIO DRG coding change 

only if that change results in noncoverage of a furnished service.

    (3) The individual who reviews changes in DRG procedural or 

diagnostic information must be a physician, and the individual who 

reviews changes in DRG coding must be qualified through training and 

experience with ICD-9-CM coding.

    (b) Procedures. Procedures described in Sec. Sec.  473.18 through 

473.36, and 473.48 (a) and (c) for a QIO reconsideration or reopening 

also apply to QIO review of a DRG coding change.

    (c) Finality of review. No additional review or appeal for matters 

governed by paragraph (a) of this section is available.



[50 FR 15372, Apr. 17, 1985; 50 FR 41887, Oct. 16, 1985. Redesignated at 

64 FR 66279, Nov. 24, 1999]