DCS, the CMS Recovery Audit Contractor (RAC) for Region A, recently posted two new issues, including DRG validations for nervous system procedures and musculoskeletal fractures. Neither of these issues, however, includes medical necessity review at this time.

The issue posted for musculoskeletal fractures is for DRG validation only and includes six MS-DRGs: 533, 534, 537, 538, 562 and 563.

The issue posted for nervous system procedures, also exclusively for DRG validation, includes 17 MS-DRGs: 020, 021, 022, 023, 024, 028, 029, 030, 031, 032, 033, 037, 038, 039, 040, 041 and 042.

Also, the RAC for Region C, Connolly Healthcare, recently posted two new automated issues: ambulance SNF-to-SNF transfers and failure to correctly bill codes on the MUE List. Both the issues concern Part B claims.

Last Friday, the Region D RAC, HDI, posted a new issue for complex review concerning minor surgery and other treatment billed as an inpatient stay that should have been billed as outpatient care. The posting, however, does not list any specific MS-DRGs.

The RAC for Region B, CGI, so far this month only has posted two new automated issues. One is for the HCPCS Code J7626, Budesonide, for which the maximum units per month exceeds 62 (per the LCD L27226) per month. The other is Multiple Surgeries reported by the same physician on the same patient on the same day.

About the Author

Ernie de los Santos is the chief information officer for eduTrax®. He joined the company at its inception and has been responsible for the creation, development and maintenance of the eduTrax® portals - a set of Web sites devoted to providing knowledge, resources and compliance aids for U.S. healthcare professionals who are involved in revenue cycle management.

Contact the Author

ernie@edutrax.net