March 18, 2010

RAC ALERT: RAC Region C Releases 25 New Approved Issues for MS-DRG Validation

By

carolSpencerConnolly Consulting Associates, the recovery audit contractor (RAC) for Region C, recently added another 25 MS-DRG validations to its approved list of issues. This brings its total to 104 MS-DRGs. Of the newly released MS-DRGs, 22 out of the 25 are surgical and 16 are with MCC or with CC.

 

Once again, the approved issues exclude "medical necessity at this time." However, as a proactive step to ward off medical necessity recoupment, astute analysts will begin their probe reviews for all cases at risk for both medical necessity and coding, which are soon to be released. Remember to validate the discharge disposition to ensure that documentation clearly supports the disposition code billed, particular for those post-acute care transfer MS-DRGs.

 

The three recently approved medical MSDRGs are listed below:

 

MS-DRG

Description

315

Other Circulatory System Diagnosis w/ MCC (post-acute care transfer MS-DRG)

933

Extensive Burns or Full-thickness Burns with Mechanical Ventilation 96+ Hours Without Skin Graft

934

Full Thickness Burn without Skin Graft or Inhalation Injury

 

The 22 recently approved surgical MS-DRGs are listed below:

 

MS-DRG

Description

133

Other Ear, Nose, Mouth, and Throat Operating Room Procedures with CC/MCC

226

Cardiac Defibrillator Implant without Cardiac Catheterization with MCC

237

Major Cardiovascular Procedures with MCC or Thoracic Aortic Aneurysm Repair

243

Permanent Cardiac Pacemaker Implant w/ CC (post-acute care transfer MS-DRG)

246

Percutaneous Cardiovascular Procedure with Drug-Eluting Stent w/ MCC or 4 or More Vessels/Stents

253

Other Vascular Procedures w/ CC

329

Major Small and Large Bowel Procedures with MCC (post-acute care transfer MS-DRG)

358

Other Digestive System O.R. Procedures without CC/MCC (post-acute care transfer MS-DRG)

415

Cholecystectomy Except by Laparoscope without C.D.E. w/ MCC

424

Other Hepatobiliary or Pancreas O.R. Procedures w/ CC

486

Knee Procedures with Principal Diagnosis of Infection w/ CC

577

Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis w/ CC

616

Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders w/ MCC (post-acute care transfer MS-DRG)

617

Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders w/ CC (post-acute care transfer MS-DRG)

675

Other Kidney and Urinary Tract Procedures without CC/MCC

717

Other Male Reproductive System O.R. Procedures Except Malignancy with CC/MCC

749

Other Female Reproductive System O.R. Procedures with CC/MCC

803

Other O.R. Procedures of the Blood and Blood-Forming Organs w/ CC

823

Lympthoma and Nonacute Leukemia with Other O.R. Procedures w/ MCC

829

Myeloproliferative Disorder or Poorly Differentiated Neoplasms with Other O.R. Procedure with CC/MCC

941

O.R. Procedure with Diagnoses of Other Contact with Health Services without CC/MCC

969

HIV with Extensive O.R. Procedure w/ MCC

 


 

Action Steps

Start performing data analytics soon on these MS-DRGs to determine your volumes and potential recoupment at risk. According to the November 2009 Comprehensive Error Rate Testing (CERT) Report, the average inpatient hospital MS-DRG paid claims error rate is 6.1 percent. To determine a good estimate of dollars at risk, run a revenue report of the volumes in each MS-DRG and multiply that number by 6.1 percent. Next, start performing probe audits and track improper payments to determine whether you are over or under the project recoupment.


About the Author

 

Carol Spencer, RHIA, CCS, CHDA is a senior healthcare consultant with Medical Learning, Inc. (MedLearn®) in St. Paul, Minn. MedLearn is a nationally recognized expert in healthcare compliance and reimbursement. Founded in 1991, MedLearn delivers actionable answers that equip healthcare organizations with coding, chargemaster, reimbursement management and RAC solutions.

(www.connollyhealthcare.com/RAC).


Contact the Author

cspencer@medlearn.com

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