Updated on: June 22, 2012

RAC ALERT: Connolly Begins RAC Reviews of Medical Necessity

By
Original story posted on: August 29, 2010

ernieConnolly Healthcare posted approvals Friday for the review of medical necessity for the same 29 MS-DRGs already cited earlier this month by two other Recovery Audit Contractors (RACs), as reported here in RACmonitor

 

Unlike those other two RACs, however, Connolly has chosen to post these approvals as "new" issues, separate from previous postings of some of the same MS-DRGs already approved for DRG Validation (with medical necessity excluded).

 

The list below indicates the DRGs as posted. Those with an asterisk (*) after the description are specifically noted by Connolly to include DRG Validation review:

 

MSDRG 689 -- Kidney and UTI
MSDRG 393 -- Other Digestive System Diagnosis
MSDRG 253, 254 -- Other Vascular Procedures *
MSDRG 249 -- Percutaneous Cardiac Procedures
MSDRG 682, 683 and 684 -- Renal Failure
MSDRG 312 -- Syncope and Collapse
MSDRG 811 -- Red Blood Cell Disorder
MSDRG 069 - TIA
MSDRG 313 -- Chest Pain *
MSDRG 291, 292, 293 -- Heart Failure and Shock *
MSDRG 391 -- Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders with MCC
MSDRG 190, 191, 192 - COPD
MSDRG 640 -- Nutritional and Misc Metabolic Disorders *
MSDRG 314, 315, and 316 -- Circulatory System Disorders *
MSDRG 056, 057 -- Degenerative Nervous System Disorders
MSDRG 302 -- Atherosclerosis *
MSDRG 308 -- Cardiac Arrhythmia *
MSDRG 551, 552 -- Medical Back Problems

 

Target: Short Stays

 

The descriptions listed are the most succinct and specific yet to be posted by any RAC. For medical necessity, the description reads as follows, with each code inserted as appropriate:

 

"RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG [XXX]. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly." (Emphasis added.)

 

For those MS-DRGs approved for both medical necessity and DRG Validation, an additional paragraph is included after the above mention of medical necessity:

 

"RACs WILL ALSO REVIEW documentation for DRG Validation requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG." (Emphasis original.)

 

This description mirrors previous language used in other postings for approval of DRG Validation, except for the previous exclusion of the review of medical necessity.

 

Plus More DRG Validations

 

In addition to the 18 new issues posted for medical necessity, Connolly posted 32 other new DRGs as approved for validation (medical necessity excluded at this time):

 

*MSDRG 254: Other Vascular Procedures without CC/MCC

*MSDRG 314: Other Circulatory System Diagnoses W MCC

*MSDRGs 280, 281, 282, 283, 284, 285, 288, 289, 290, 292, 293, 296, 297, 298, 299, 300, 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 311, 313, 314, 316: Cardiovascular Diseases

 

No Edits to Existing Posts (Yet)

 

Previously listed MS-DRGs with approval for DRG Validation only, excluding medical necessity, neither have been edited nor removed from Connolly's list as of 4 p.m. EST, Aug. 27.

 

The Connolly list includes neither the date of posting nor approval of their issues, nor do they include any internal issues "numbers" as seen on the other three RAC websites.

 

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.

 

Contact the Author

 

ernie@edutrax.net

 

 

 

 

 

 

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