Updated on: January 30, 2013

Region A RAC Reposts Four Issues for Maryland

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Original story posted on: August 1, 2011

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DSC Healthcare has translated four issues originally posted as all patient refined diagnosis-related groups (APR-DRGs) to Medicare severity diagnosis-related groups (MS-DRGs). The issues affect Maryland inpatient hospitals, the Region A recovery audit contractor (RAC) said on its website.

The RAC said using MS-DRGs will be “more beneficial and less impactful to providers” because Maryland hospital billing departments submit claims through the CMS Grouper using MS-DRGs. It also will make responding to additional documentation requests (ADRs), result letters and demand letters easier if the RAC uses the same MS-DRGs that the Medicare administrative contractor used, the RAC said.

 

Maryland hospitals that had received ADRs with APR-DRGs will receive updated letters with the MS-DRGs, the RAC said. DSC Healthcare said it had sent ADRs only for medical necessity review of APR 203 (chest pain) and APR-DRGs associated with MS-DRG 313 (chest pain).
The issues are below.

Inpatient Hospital

Name of issue Date posted or approved Regions/states where it is active Description of issue Document sources
Medical necessity review for MS-DRG 313 – chest pain (all severity and risk of mortality levels) 7/27/11 Md. 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. Section 1886(d) of Social Security Act; CMS Pub 100-08, 100-02, 100-04; Highmark LCD L27548; Maryland Health Services Cost Review Commission; Pepper Report; OIG Reports A-01-10-01000, A-03-00-00007, OAI-05-88-00730
Medical necessity review for MS-DRG 312 – syncope (all severity and risk of mortality levels) 7/27/11 Md. 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. Section 1886(d) of Social Security Act; CMS Pub 100-08, 100-02, 100-04; Highmark LCD L27548; Maryland Health Services Cost Review Commission; Pepper Report; OIG Reports A-01-10-01000, A-03-00-00007, OAI-05-88-00730
Medical necessity review for MS-DRG 069 transient ischemia (all severity and risk of mortality levels) 7/27/11 Md. 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. Section 1886(d) of Social Security Act; CMS Pub 100-08, 100-02, 100-04; Highmark LCD L27548; admission of less than 24 hours policy; Pepper Report; OIG Reports A-01-10-01000, A-03-00-00007, OAI-05-88-00730
Medical necessity review for MS-DRG 190, 191, 192 – chronic obstructive pulmonary disease (all severity and risk mortality levels) 7/27/11 Md. 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. Section 1886(d) of Social Security Act; CMS Pub 100-08, 100-02, 100-04; Highmark LCD L27548; admission of less than 24 hours policy; Pepper Report; OIG Reports A-01-10-01000, A-03-00-00007, OAI-05-88-00730
Karen Long

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