April 26, 2010

Connolly Adds 20 New Issues

By

ernieVirginia, West Virginia Also Added


Connolly Healthcare, the RAC for Region C, posted 20 new DRG Validation Issues to their list of CMS-Approved audit issues, on Friday, April16. The new issues include eight (8) MS-DRGs with very high Relative Weights (which equates to high dollar reimbursements and thereby potentially high RAC fees). Also, six (6) of the new issues have claim volumes in the top 25% of all DRGs (as measured by the number of discharges with that DRG nationwide). A high volume of discharges provides a corresponding large number of claims for the RAC to potentially audit.

Four of the new issues are for MSDRGs with Relative Weights (RW) of better than 10.0. One of them -- MSDRG 001, Heart Transplant -- has one of the highest RWs: 24.85.  A high RW produces a high dollar reimbursement, since the Relative Weight of a DRG is used to calculate a facility's payment. A simple approximation of a payment can be calculated by multiplying the Relative Weight by a facility's Medicare Blended Rate, a dollar amount which is calculated and assigned by CMS every year for all facilities who bill Medicare under the Inpatient Prospective Payment System. The average Medicare Blended Rate nationwide is roughly $4500. Therefore, a DRG with an RW of 10.0 would likely pay a facility approximately $45,000 per claim.

 

Since Connolly's contigency fee is 9.0% (by contract with CMS), the RAC's fee for a $45,000 recoupment would be $4,050.

 

Virgina and West Virginia Now Included


The states of Virginia and West Virginia have been absent from the list of states affected or approved for any issues, until some recent changes to the lists, earlier in April. Still, not all the issues have been approved for these two states.


The New Issues


Below are the new posted and approved audit issues for RAC Region C, including Relative Weights and FY09 Discharge Ranks:  (a low rank number relates to a large number of discharges for that DRG, and vice versa)

 

MS-DRG 003

ECMO or Tracheotomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R.  (RW 18.27; Rank 122)

MS-DRG 001 Heart Transplant or Implant of Heart Assist System with MCC  (RW 24.85; Rank 720)
MS-DRG 005 Liver Transplant with MCC or Intestinal Transplant  (RW 10.14; Rank 713)
MS-DRG 332 Rectal Resection with MCC (RW 4.78; Rank 297)
MS-DRG 562 Kidney Transplant (RW 1.38; Rank 79)
MS-DRG 011 Tracheotomy for Face, Mouth, and Neck Diagnoses with MCC (RW 4.73; Rank 476)
MS-DRG 012 Tracheotomy for Face, Mouth, and Neck Diagnoses with CC (RW 3.03; Rank 584)
MS-DRG 020 Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with MCC (RW 8.44; Rank 696)
MS-DRG 021 Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with CC (RW 6.21; Rank 696)
MS-DRG 927 Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours with Skin Graft (RW 13.74; Rank 629)
MS-DRG 929 Full Thickness Burn with Skin Graft or Inhalation Injury without CC/MCC (RW 2.01; Rank 728)
MS-DRG 023 Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis with MCC or Chemo Implant (RW 4.94; Rank 469)
MS-DRG 024 Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis without MCC (RW 3.26; Rank 212)
MS-DRG 007 Lung Transplant (RW 9.45; Rank 689)
MS-DRG 076 Viral Meningitis without CC/MCC (RW 0.83; Rank 510)
MS-DRG 461 Bilateral or Multiple Major Joint Procedures of Lower Extremity with MCC (RW 4.56; Rank 187)
MS-DRGs 799, 800, 801 Splenectomy w MCC, w CC, w/o CC/MCC (RW 5.11, 2.53, 1.59; Ranks 666, 709, 620)
MS-DRG 177 Respiratory Infections & Inflammations with MCC (RW 2.05; Rank 35)
MS-DRG 178 Respiratory Infections & Inflammations with CC (RW 1.49; Rank 132)
MS-DRG 179 Respiratory Infections & Inflammations without CC/MCC (RW 1.01; Rank 119)

 

 



 

To see the complete original listings (on the RAC websites), visit this page.

 

Still No Medical Necessity Reviews


All of the above approved issues still include this caveat:


(At this time, Medical Necessity excluded from review).


As faithful readers know, however, Medical Necessity Reviews could be approved by CMS at any time now, since the CMS RAC Review Phase-In Strategy allows for such audits in calendar 2010.

 

We will shortly post further analysis, in an overview of the DRG Validations posted to date by all four RACs.


About the Author


Ernie de los Santos is the chief information officer at 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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