Updated on: June 22, 2012

CMS May Have Already Approved Medical Necessity Reviews

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Original story posted on: May 24, 2010

ernieDuring the May 5, 2010 RAC 101 Conference Call, Scott Wakefield, a CMS RAC Project Manager for Region B stated that providers may begin to receive RAC medical necessity reviews "within the next month or so."

 

According to one listener with whom I spoke, Mr. Wakefield seemed somewhat surprised that no such reviews have been posted by the RACs, as yet, and intimated that such issues had already been approved.

Meanwhile, in the past two weeks, the RAC have all posted new issues, but none with medical necessity reviews approved.

 

The new issues are listed below:

 

Region A


While the RAC for Region A (DCS) only posted one new issue, it is not a small issue, especially since it is NOT tied to a single MSDRG, but is instead tied to ICD-9 Code 042:


MS-DRG Validation for HIV.

 

The description reads: "Reviewers will validate claims where diagnosis code 042 Human Immunodeficiency Virus (HIV) Disease was billed as secondary."

 

This is currently the only DRG Validation issue that appears without a specific DRG identified, and this issue was also approved for Region B, back in March. Region C is approved for HIV review, although in their case it specifies a single DRG, MS-DRG 969: HIV with Extensive O.R. Procedure with MCC. Region D, however, is approved for a more extensive list, MSDRGs 969, 970, 974, 975, 976, 977: DRG Validation-HIV Infections. Looking at the Relative Weights of those issues, three of them are better than 2.0, and the Relative Weight for 969 is 5.5 -- or in dollars, each claim for 969 produces an average reimbursement of better than $20,000 per claim.

 

Word to your RAC Team Leader: while there are not many discharges for MS-DRG 969, one of those six listed above is in the top 100 for discharges: MS-DRG 977.

 

Region B


CGI Federal added a large number of DRG Validation issues during March, but so far this month, they have added only two new issues: one for Automated Review and one issue that includes 3 DRG Validations:

 

  • Knee Orthoses: concerns certain additions not being separately payable.

 

  • MSDRG 239, 240, 241: DRG Validation for Amputation for Circulatory System Disorders Except Upper Limb and Toe.

 

The Relative Weights are 4.72, 2.53 and 1.49, respectively. MS-DRG 241 is likely a high risk for any facility, since it is ranked #127 for discharges.

 

Region C

 

Connolly Healthcare posted 19 new issues, including 21 new DRG Validations:

 

 

Darbepoetin alfa (non-ESRD) - Dose vs. Units Billed

Bevacizumab - Dose vs. Units Billed

Carboplatin - Dose vs. Units Billed

Docetaxel - Dose vs. Units

Irinotecan - Dose vs. Units Billed

Darbepoetin alfa (ESRD) - Dose vs. Units Billed

MS-DRG 040: Peripheral/Cranial Nerve and Other Nervous System Procedures with MCC

MS-DRG 841: Lymphoma and Nonacute Leukemia with CC

MS-DRG 258: Cardiac Pacemaker Device Replacement with MCC

MS-DRG 653: Major Bladder Procedure with MCC

MS-DRG 659: Kidney and Ureter Procedures for Non-Neoplasm with MCC

MS-DRG 326: Stomach, Esophageal and Duodenal Procedures with MCC

MS-DRG 009: Bone Marrow Transplant: MS-DRG 009

MS-DRG 328: Stomach, Esophageal and Duodenal Procedures without CC/MCC

MS-DRG 623: Skin Grafts/Wound Debridement for Endocrine, Nutri'l & Metab. Disorders w/CC

MS-DRG 802: Other O.R. Procedures of the Blood and Blood-Forming Organs with MCC

MS-DRGs 034, 035, 036, 215, 223, 224, 225, 231, 232, 286: Cardiac Procedures

MS-DRG 541: Osteomyelitis without CC/MCC

DME vs. Inpatient


We would especially call readers' attention to the Cardiac Procedures DRGs.



Region D

 

Even HDI found a new issue to add, albeit one for Automated Review (after all, they have almost all the DRGs now):

 

Part B Duplicates - Automated Review

 

When Will Medical Necessity Reviews Begin?

 

No one knows but the RACs, and so far, they ain't sayin'.

 

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 site devoted to providing knowledge, resources and compliance aids for U.S. healthcare professionals who are involved in revenue cycle management.

 


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ernie@edutrax.net

 


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