July 25, 2011

RACs Continue to Target Hospitals

By

klong100

 

alert-powered-by-decision-health

 

 

 

 

 

 

The majority of the issues that three of the four Recovery Audit Contractors (RACs) posted last week targeted hospitals.

In RAC Region B, CGI Federal posted three issues for MS-DRG validation that excluded medical necessity. HealthDataInsights, the RAC in Region D, posted seven acute-inpatient hospitalization issues that did target medical necessity. DCS Healthcare in Region A posted one issue relating to durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). Region C RAC Connolly did not post issues last week.

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue Document sources
Aftercare – musculoskeletal system: MS-DRGs 559-561 (medical necessity excluded) 7/18/11 RAC Region B The purpose of MS-DRG Validation is to determine that the principal diagnosis and all secondary diagnoses identified as CCs and MCCs are actually present, correctly sequenced, coded and clinically validated. When a patient is admitted to the hospital, the condition established after study found to be chiefly responsible for occasioning the admission to the hospital should be sequenced as the principal diagnosis. The other diagnosis identified should represent all (MCC/CC) present during the admission that impact the stay. The POA indicator for all diagnoses reported must be coded correctly. PIM Ch 6.5.3, section A-C; present on admission indicator systems implementation
Biliary tract procedures: MS-DRGs 408-410 (medical necessity excluded) 7/18/11 RAC Region B The purpose of MS-DRG Validation is to determine that the principal diagnosis and all secondary diagnoses identified as CCs and MCCs are actually present, correctly sequenced, coded and clinically validated. When a patient is admitted to the hospital, the condition established after study found to be chiefly responsible for occasioning the admission to the hospital should be sequenced as the principal diagnosis. The other diagnosis identified should represent all (MCC/CC) present during the admission that impact the stay. The POA indicator for all diagnoses reported must be coded correctly. PIM Ch 6.5.3, section A-C; present on admission indicator systems implementation
Hepatobiliary Procedures: MS-DRGs 420-425 (medical necessity excluded) 7/18/11 RAC Region B The purpose of MS-DRG Validation is to determine that the principal diagnosis and all secondary diagnoses identified as CCs and MCCs are actually present, correctly sequenced, coded and clinically validated. When a patient is admitted to the hospital, the condition established after study found to be chiefly responsible for occasioning the admission to the hospital should be sequenced as the principal diagnosis. The other diagnosis identified should represent all (MCC/CC) present during the admission that impact the stay. The POA indicator for all diagnoses reported must be coded correctly. PIM Ch 6.5.3, section A-C; present on admission indicator systems implementation
Acute inpatient hospitalization – traumatic stupor and coma, coma less than one hour without CC/MCC (DRG 087) 7/7/11 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, 100-08
Acute inpatient hospitalization – concussion without CC/MCC (DRG 090) 7/7/11 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, 100-08
Acute inpatient hospitalization – reticuloendothelial and immunity disorders with CC (DRG 815) 6/27/11 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, 100-08
Acute inpatient hospitalization – reticuloendothelial and immunity disorders with MCC (DRG 814) 6/27/11 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, 100-08
Acute inpatient hospitalization – reticuloendothelial and immunity disorders without CC/MCC (DRG 816) 6/27/11 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, 100-08
Acute inpatient hospitalization – coagulation disorders (DRG 813) 6/27/11 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, 100-08
Acute inpatient hospitalization – pulmonary edema and respiratory failure (DRG 189) 6/27/11 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, 100-0

 

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 health care business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

Karen Long

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