---
kind: "section"
citation: "42 C.F.R. § 478.15"
title: "42"
number: "478.15"
heading: "QIO review of changes resulting from DRG validation."
url: "https://uscodex.org/cfr/42/478.15"
---

# §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](/cfr/42/478.18..478.36.md) and [478.48(a)](/cfr/42/478.48.md?p=a) and [(c)](/cfr/42/478.48.md?p=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)](#a) of this section is available.

## Notes

### Amendments

[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]

### Source

Source: 50 FR 15372, Apr. 17, 1985, unless otherwise noted. Redesignated at 64 FR 66279, Nov. 24, 1999.

### Authority

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

### Amendments

[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]