February 4, 2009

Likely RAC Targets Revealed

By
cservais120dsBy Cheryl E. Servais, MPH, RHIA


The Recovery Audit Contractors (RACs) focused on a variety of issues. In the end, they had corrected more than $1.03 billion of improper Medicare payments.

 

Now, based on the lists of DRGs selected for review by the demonstration RACs, Office of Inspector General, (OIG), and Program for Evaluating Payment Patterns Electronic Report (PEPPER) reports, I have created a list of those MS-DRGs and medical necessity issues likely to be targeted for review by the permanent RACs. Facilities can use this list as a basis for auditing recent Medicare claims (those submitted since October 1, 2007).

 

Risk areas should be addressed with coding audits, coding education, clinical documentation improvement programs, utilization review and case management guidelines, medical necessity guidelines and physician education.

 

Inpatient


• Respiratory Dxes w/Ventilator (old DRG 76) (incorrect code)
- MSDRG 166 - Other Respiratory System OR Procedures w/MCC
- MSDRG 167 - Other Respiratory System OR Procedures w/CC
- MSDRG 168 - Other Respiratory System OR Procedures w/o CC/MCC

• Respiratory Infections & Inflammations, Age > 17 w/CC (old DRG 79) ¹(incorrect code)
- MSDRG 177 Respiratory Infections & Inflammations w/MCC
- MSDRG 178 Respiratory Infections & Inflammations w/CC
- MSDRG 179 Respiratory Infections & Inflammations w/o CC/MCC

 

• Respiratory System diagnosis with Ventilator Support (old DRG 565/566) ¹(incorrect code)
- MSDRG 207 Respiratory System diagnosis w ventilator support 96+ hours
- MSDRG 208 Respiratory system diagnosis w ventilator support <96 hours

• Other Circulatory System OR Procedures (old DRG 120) ¹ (incorrect code)
- MSDRG 264 Other circulatory system OR Procedures

• MS DRGs 286/287 - Circulatory Disorders except AMI w/Caridac Cath w MCC/woMCC2
- Treated in wrong setting (medically unnecessary)

 

• MS DRGs 291/292/293 Heart Failure/Shock w MCC/w CC/wo CC/MCC2
- Treated in wrong setting (medically unnecessary)
- Coding errors

 

• MS DRGs 308/309/310 Cardiac arrhythmia & Conduction disorders wMCC/w CC/wo CC/MCC (incorrect code)

 

• Chest pain (Old DRG 143) ¹(medical necessity)
- MSDRG 313 Chest Pain

 

• Excisional Debridement (incorrect code)¹,²
- Wound Debridement & Skin graft except hand, for musculoskeletal and connective tissue disorders (old DRG 217)

  • MSDRG 463 Wound debridement & skin graft except hand for musculoskeletal connective tissue disease w MCC
  • MSDRG 464 Wound debridement & skin graft except hand for musculoskeletal connective tissue disease w CC
  • Wound debridement & skin graft except hand for musculoskeletal connective tissue disease w/o CC/MCC

 

- Medical Back Problems (old DRG 243) (medical necessity)

  • MSDRG 551 Medical Back Problems w/MCC
  • MSDRG 552 Medical Back Problems w/oMCC

 

- Skin Graft and/or Debridement for Skin Ulcer or Cellulitis w/CC(old DRG 263)¹,² (correct coding)

  • MSDRG 573 Skin graft &/or debridement for skin ulcer or cellulitis w/MCC
  • MSDRG 574 Skin graft &/or debridement for skin ulcer or cellulitis w/CC
  • MSDRG 575 Skin graft &/or debridement for skin ulcer or cellulitis w/o CC/MCC

 

• MS DRGs 640/641 Nutritional & Metabolic disorders wMCC/woMCC (correct coding)

 

• Septicemia (old DRG 576)¹,² (coding)
- MSDRG 870 Septicemia w MV 96+ hours
- MSDRG 871 Septicemia w/o MV 96+ hours w/MCC
- MSDRG 872 Septicemia w/o MV 96+ hours w/o MCC

 

• Extensive OR Procedure unrelated to principal diagnosis (old DRG 468) ¹(coding)
- MSDRG 981Extensive OR procedure unrelated to principal diagnosis w/MCC
- MSDRG 982 Extensive OR procedure unrelated to principal diagnosis w/CC
- MSDRG 983 Extensive OR procedure unrelated to principal diagnosis w/oCC/MCC
- MSDRG 853 Infectious & parasitic diseases w OR procedure w/MCC
- MSDRG 854 Infectious & parasitic diseases w OR procedure w/CC
- MSDRG 855 Infectious & parasitic diseases w OR procedure woCC/MCC

 

• Other Cases with high MS-DRG weight with low charges or LOS (coding)

 

• MCC/CC triplet rate (high % of claims assigned to MS-DRGs with MCC or CC in comparison with other facilities) (coding)

Discharge Status Codes²

 

Patients went to sub acute care and billed with "01"

 

Outpatient²

 

  • Neulasta (medically unnecessary)
  • Speech Language Pathology (medically unnecessary)
  • Therapy units billed(medically unnecessary)
  • Infusion Services (medically unnecessary)

- Multiple Colonoscopies (45355, 45378, 45380, 45383, 45384, 45385) (medically unnecessary)
- Multiple procedures on the same day (medically unnecessary)

  • E.g. CPT code 47562 (Cholecystectomy) 3 units billed

• Outpatient charges without Medical Necessity diagnoses (LCD or NCD)


• Inpatient Medical Necessity Targets
- Short Stays with weak principal diagnoses

  • Abdominal Pain
  • Asthma
  • Dehydration
  • Diabetes

- 1 day stays
- 3-day stays with discharge status of discharge to SNF
- Readmissions within 72 hours of discharge
- IRF following joint replacement surgery
- Cardiac defibrillator implant in wrong setting
- 7 day readmit to same or other acute facility (early discharge?)



There are other targets to consider as well. The Office of Inspector General (OIG) and other CMS agencies have a list of targeted DRGs which the RAC may use as a basis for a complex review. These targets are:

 

Old DRG

Description

MS-DRG

014

Intracranial Hemorrhage & Stroke with Infarction

064, 065, 066

015

Nonspecific Cerebrovascular and precerebral occlusion without infarction

067, 068

524

Transient Ischemia

069

 


 


 


079

Respiratory infections & inflammations >17 w/CC

177, 178

080

Respiratory infections & inflammations w/oCC

179

089

Simple Pneumonia & Pleurisy >17 w/CC

193

 


 


 


087

Pulmonary edema & Respiratory failure

189

088

COPD

190, 191, 192

127

Heart Failure & Shock

291, 292, 293

 


 


 


088

COPD

190, 191, 192

096

Bronchitis & Asthma >17 w/CC

202

 


 


 


089

Simple Pneumonia & Pleurisy >17 w/CC

193

096

Bronchitis & Asthma >17 w/CC

202

 


 


 


121

Circulatory Disorders w/AMI & Major Complications, Discharged Alive

280

124

Circulatory Disorders except AMI w/Cardiac cath and complex diagnosis

286

 


 


 


122

Circulatory Disorders w/AMI wo major complications, discharged alive

281, 282

125

Circulatory Disorders except AMI w/Cardiac cath wo complex diagnosis

287

 


 


 


127

Heart Failure & Shock

291, 292, 293

140

Angina Pectoris

311

 


 


 


130

Peripheral Vascular Disorders w/CC

299, 300

128

Deep Vein Thrombophlebitis

294, 295

 


 


 


132

Atherosclerosis w/CC

302

140

Angina Pectoris

311

 


 


 


138

Cardiac arrhythmia & conduction disorders w/CC

308, 309

140

Angina Pectoris

311

 


 


 


140

Angina Pectoris

311

143

Chest Pain

313

 


 


 


174

GI Hemorrhage w/CC

377, 378

182

Esophagitis, Gastroenteritis, & Misc, Digestive Disorders >17 w/CC

391

 


 


 


188

Other Digestive System Diagnosis >17w/CC

393, 394

180

GI Obstruction w/CC

389

 


 


 


239

Pathological Fracture & Musculoskeletal & Connective Tissue Malignancy

542

243

Medical Back Problems

551, 552

 


 


 


296

Nutritional & Misc. Metabolic Disorders >17 w/CC

640

182

Esophagitis, Gastroenteritis & Misc. digestive disorders >17 w/CC

391

 


 


 


316

Renal failure

682,683

331

Other Kidney & Urinary tract diagnoses >17 w/CC

698, 699

 


 


 


320

Kidney & UTI >17 w/CC

689

296

Nutritional & Misc. metabolic disorders >17 w/CC

640

 


 


 


416

Septicemia >17

871, 872

320

Kidney & UTI >17 w/CC

689

 


 


 


430

Psychoses

885

425

Acute Adjustment Reactions & disturbances of psychosocial dysfunction

880

 


 


 


565, 566

Respiratory system diagnosis with ventilator support

207, 208

121

Circulatory disorders w/AMI & major complications, discharged alive

280, 281, 282

 


 


 


565, 566

Respiratory system diagnosis with ventilator support

207, 208

127

Heart Failure & Shock

291, 292, 293

 


 


 



In the coming months, I will present in depth discussions of these targets and the pertinent coding and medical necessity issues involved.

 

____________________

¹ VHA Presentation 2008

² The Medicare Recovery Audit Contractor (RAC)Program: Update to the Evaluation of the 3-year Demonstration June 2008

 

###

 

About the Author

 

Cheryl Servais has more than 25 years of experience in Health Information Management. In her position at Precyse Solutions, Ms. Servais' responsibilities include planning, designing, implementing and maintaining corporate-wide compliance programs, policies and procedures, and updating them to accommodate changes in federal and other regulations. In addition, she oversees training and development programs related to ethics, compliance and patient privacy; develops and chairs compliance and privacy advisory committees at the Executive and Board levels; and takes an active role in professional organizations.

 

Cheryl E. Servais, MPH, RHIA, is Vice President, Compliance and Privacy Officer for Precyse Solutions

About the Author | Contact the Author

 

Cheryl E. Servais, MPH, RHIA

This email address is being protected from spambots. You need JavaScript enabled to view it.