Updated on: January 31, 2013

Medical Necessity Dominates New RAC Issues

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Original story posted on: October 31, 2011

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The two recovery auditors that posted issues last week listed a slew of medical necessity reviews.

DCS Healthcare Services, the Region A RAC, posted four issues for Part A providers in Maryland about surgical cardiovascular procedures, renal and urinary tract disorders, infections and musculoskeletal disorders.

HealthDataInsights, the Region D RAC, posted 26 issues for short-term acute care hospitals ranging from allergic reactions with major complications and comorbidities to alcohol/drug abuse or dependence with rehabilitation therapy.

For more, see the chart below.

Part A

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review – Surgical cardiovascular procedures, MS-DRGs 246-254, 263-265

10/26/11

Md.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sections 1886(d) and 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Pepper Report; OIG reports A-01-10-01000, A-03-00-00007, OIA-05-88-00730; Change request 3200; Admission of less than 24 hours policy – Maryland

Medical necessity review – Renal and urinary tract disorders

10/26/11

Md.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sections 1886(d) and 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Pepper Report; OIG reports A-01-10-01000, A-03-00-00007, OIA-05-88-00730; Change request 3200; Admission of less than 24 hours policy – Maryland

Acute inpatient hospitalizations – infections, MS-DRGs 094-096, 177-179, 488-489, 539-541, 602-603, 689-690, 856-858, 862-869, 871-872, 977

10/26/11

Md.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Section 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapters 1, 6; Change request 3200; Admission of less than 24 hours policy – Maryland

Acute inpatient hospitalization – musculoskeletal disorders

10/26/11

Md.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Section 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapters 1, 6; Change request 3200; Admission of less than 24 hours policy – Maryland

 


Inpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute inpatient hospitalization – malignancy of hepatobiliary system or pancreas with CC (DRG 436)

10/6/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – allergic reactions with MCC (DRG 915)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – complications of treatment with CC (DRG 920)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – traumatic injury with MCC (DRG 913)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – allergic reactions without MCC (DRG 916)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – other factors influencing health status

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

 


Acute inpatient hospitalization – poisoning and toxic effects of drugs with MCC (DRG 917)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – signs and symptoms with MCC (DRG 947)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – other injury, poisoning and toxic effect diagnosis with MCC (DRG 922)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – other injury, poisoning and toxic effect diagnosis without MCC (DRG 923)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – alcohol/drug abuse or dependence without rehabilitation therapy without MCC (DRG 897)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – disorders of pancreas except malignancy with CC (DRG 439)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – lymphoma and non-acute leukemia with MCC (DRG 840)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

 


Acute inpatient hospitalization – malignancy of hepatobiliary system or pancreas without CC/MCC (DRG 437)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – disorders of pancreas except malignancy with MCC (DRG 438)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – other myeloproliferative disease or poorly differentiated neoplasm diagnosis without CC/MCC (DRG 845)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – alcohol/drug abuse or dependence with rehabilitation therapy (DRG 895)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – alcohol/drug abuse or dependence without rehabilitation therapy with MCC (DRG 896)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – acute adjustment reaction and psychosocial dysfunction (DRG 880)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – disorders of personality and impulse control (DRG 883)

10/13/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

 


 

Acute inpatient hospitalization – other multiple significant trauma with MCC (DRG 963)

10/14/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – other multiple significant trauma with CC (DRG 964)

10/14/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – other myeloproliferative disease or poorly differentiated neoplastic diagnosis with CC (DRG 844)

10/14/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – chemotherapy without acute leukemia as secondary diagnosis with MCC (DRG 846)

10/14/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with MCC (DRG 441)

10/14/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – traumatic stupor and coma, coma less than one hour with CC (DRG 086)

10/19/11

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

 

About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

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KLong@decisionhealth.com

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