42 CFR §478.15

1. (a)General rules.
   1. (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—
      1. (i)The change caused an assignment of a different DRG; and
      2. (ii)Resulted in a lower payment.
   2. (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. (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.
2. (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.
3. (c)Finality of review. No additional review or appeal for matters governed by paragraph (a) of this section is available.