Updated on: June 22, 2012

Region A RAC Posts 21 New Issues, Including 110 DRGs Some Approved for Medical Necessity Review

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Original story posted on: December 22, 2010

ernieDCS Healthcare, the Recovery Audit Contractor (RAC) for CMS Region A, on the morning of Dec. 7 posted 21 new CMS-approved issues for RAC review, including 110 new DRG Validations. The posting also announced medical necessity review for Renal and Urinary Tract Disorders, which would include at least 19 MS-DRGs, some never before approved for such review by any of the other RACs.

 

New Issues Include 110 New DRGs

 

The list below shows the 21 new postings:

 

1.       Inpatient Admissions without a Physician's Inpatient Admit Order

2.       Medical Necessity Review (MNR) - Renal and Urinary Tract Disorders

3.       Carotid Artery Stent Procedures

4.       Other Respiratory System O.R. Procedures

5.       Amputations

6.       Circulatory Disorders Except Acute Myocardial Infarction, with Cardiac Catheterization

7.       Stomach, Esophageal and Duodenal Procedures

8.       Other Digestive System O.R. Procedures

9.       Major Gastrointestinal Disorders and Peritoneal Infections

10.     Pancreas, Liver and Shunt Procedures

11.     Hepatobiliary System and Pancreas Disorders (MDC 6)

12.     Spinal Fusion

13.     Post Operative Anemia

14.     Cervical Spinal Fusions

15.     O.R. Procedures for Obesity

16.     Urinary Procedures

17.     Metastasis

18.     Neoplasm Surgery

19.     Neoplasm

20.     Other OR Procedures for Injuries

21.     Place of Service Coding for Physician Services

 

To repeat, the list above includes 110 new MS-DRGs approved for DRG Validation.

 

Providers in Region A also should be mindful of two automated issues now posted: Inpatient Admissions without a Physician's Inpatient Admit Order, and Place of Service Coding for Physician Services. This is the first time that Place of Service Coding has been added by any RAC, since recommended by the OIG, which found a 90 percent error rate in a small sample survey conducted by them, earlier this year.

 

Medical Necessity Approved for Other DRGs

 

As for the announced Medical Necessity Review (MNR) of any Medicare claims submitted for Renal and Urinary Tract Disorders. This likely includes all MS-DRGs included in the Medical DRGs in MDC 11, Diseases and Disorders of the Kidney and Urinary Tract: a total of 19 total MS-DRGs, Nos. 682 through 700.

 

Unlike postings by other RACs, it is not clear from the language on DCS Healthcare's website if these Medical Necessity Reviews will include DRG Validation or coding/billing review. However, some might argue that it is unlikely that a review of medical necessity would not include a review of the medical coding submitted.

 

Problems Noted in the DCS Postings

 

One of the postings, the one for Amputations, actually had the wrong MS-DRGs listed: 286 and 287, which elsewhere were listed correctly for Circulatory Disorders. A few days after the original postings, however, the MS-DRGs listed in the description of the issue were corrected by DCS.

 

Another posting, for Pancreas, Liver and Shunt Procedures, mentions neither exclusion nor inclusion of medical necessity review. It is the only DRG Validation posting by DCS that does not mention MNR one way or the other.

 

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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