Updated on: June 22, 2012

RACs Post Many New Issues: 23 New Medical Necessity Issues Connolly Posts 77 New Issues, DCS Posts 7 New Issues

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Original story posted on: January 20, 2011

ernieConnolly Healthcare, the Recovery Audit Contractor (RAC) for Region C posted 77 new issues and DCS, the RAC for Region A posted seven new issues, continuing the pattern that healthcare providers have come to expect from all four RACs - postings that present confusing, incomplete and oftentimes contradictory information.

 

The posting took place late in the day on Friday, Jan. 14, 2011. The RACs are required by CMS to post their approved review issues on a public website before they can begin any widespread review of said issues.  No format, however, is stipulated in the Statement of Work for the website or for the pages listing the issues.

 

The postings made last Friday continue with no consistent format for these webpages. Connolly's postings added some 17,000 words to their page, the largest single day's changes made to any of the four RAC websites.

 

DCS: All DRG Validation

 

While only posting seven new issues, DCS posted 68 more MSDRGs approved for DRG Validation. Only three of the seven list the MSDRGs in the title field (Issue Name). One issue's title seems to suggest that it covers MDC 18, but then in fact only includes 16 of the 17 MSDRGs in that MDC.

 

Another issue title suggests it covers MDC 1, but only lists five of the 75 MSDRGs in that MDC. Only two other postings on the DCS site mention MDCs and neither includes even half of all MSDRGs in those MDCs.

 

Most DRG Validation postings do not mention an MDC even if the issue includes multiple MSDRGs. Many posts list only a single MSDRG.

 

Connolly: DRG Validations, Medical Necessity, and Both

 

Of the 77 new issues posted by Connolly some list approval for a single MS-DRG while some list approval for multiple MS-DRGs including anywhere from two to 32 in a single post. Of the 77 issues, we find:

 

  • 54 issues concern DRG Validation only for specified MSDRGs,
  • 19 issues concern Medical Necessity only for specified MSDRGs, and
  • 4 issues cover both DRG Validation for specified MSDRGs and Medical Necessity for some of the same MSDRGs.


If we count the number of MS-DRGs involved we find:

  • 216 MSDRGs newly approved for DRG Validation
  • 70 MSDRGs newly approved for Medical Necessity Review


Of the 70 MSDRGs approved for Medical Necessity Review, 46 are identified separately while 24 are buried inside lists of MS-DRGs also approved for DRG Validation. We say "buried" because the specific MS-DRGs approved for Medical Necessity Review are posted in a very confusing manner.

 

For example, here is the Issue Name (title) for a posting that includes both DRG Validation and Medical Necessity Review:

 

Hepatobiliary Disorders (At this time, Medical Necessity will be excluded from review for DRG(s) 434, 435, 436, 437, 438, 439, 440, 441, 443, 445)

 

The Description field for this issue includes a list of the MSDRGs that the issue covers:

 

"Reviewers will validate principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS DRG 434, 435, 436, 437, 438, 439, 440, 441, 442, 443, 444, 445, 446."

 

This method of listing the MSDRGs requires the reader to compare the two long lists of MSDRGs in the posting in order to determine which MSDRGs are approved for Medical Necessity Review. In doing this comparison just three MSDRGs - 442, 444, 446 - are identified.

 

We have been told that the RACs are supposed to post new issues on their webpage exactly as they are approved, with the exact same language that is used in the many forms they are required to submit to CMS to garner approval for widespread review.

 

Many providers are wondering (out loud, at least to this reporter) how it can be that Connolly can be making so many changes/edits or making such confusing posts if that is true.

 

Some wonder if anyone is paying attention to what the RACs post.

 

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 websites 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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