Title 42

SECTION 478.15

478.15 QIO review of changes resulting from DRG validation.

§ 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 §§ 478.18 through 478.36 and 478.48(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; 77 FR 68563, Nov. 15, 2012]

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