Updated on: June 22, 2012

Region C RAC Posts 35 New Issues, 100+ DRGs

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Original story posted on: November 21, 2010

 

ernieConnolly Healthcare, the Recovery Audit Contractor (RAC) for 17 states, posted 35 new issues and removed four older issues on its “approved issues” Web page last week. The postings continued a pattern of confusing and incomplete information that healthcare providers have come to expect from the four RACs during recent months.


While the RACs are required by CMS to post their approved review issues on a public website, there is no format stipulated for the websites, nor for the individual pages listing the issues. The postings made last week are a prime example of how inadequate these listings can be.


Sixteen of the 35 new issues posted list approval for a single MS-DRG, 14 issues list approval for multiple MS-DRGs (anywhere from two to 18), and five issues list approval for an indeterminate number of MS-DRGs – that is, they list no MS-DRGs whatsoever, only citing disorders, conditions or procedures in rather generalized terms. Those generalized terms lead us to deduce that Connolly intends to include broad ranges of MS-DRGs under those issues. Unfortunately, those same five issues include approval for medical necessity review and most probably include DRG validation as well (the description indicates that records will be reviewed to determine that services paid for not only were medically necessary, but were coded and billed correctly.)

 

Deletions vs. Edits

 

In the past, Connolly has edited previously posted issues when medical necessity was approved for one or more of the MS-DRGs listed in them. Last week, however, instead of editing a previous posting, the older posting was deleted and a "new" edited version was added as if it were a "new" issue. This was done for four separate issues covering MS-DRGs 177, 178, 179 and 488. In each of these posts, the parenthetical phrase "(at this time, medical necessity excluded from review)" was removed.


In the case of the issues covering MS-DRGs 177, 178 and 179, mention of approved medical necessity review in fact was added, assuming we have interpreted the postings correctly. For MS-DRG 488, however, there is not yet an issue listed that specifically states that it has been approved for review of medical necessity.


We are submitting questions to both CMS and Connolly to get some clarification on the new postings, and will report back when we receive answers.


DRG Validations


Below is a list of the 30 new postings that specifically cite a combined total of 94 MS-DRGs approved for DRG validation review. The titles below, however, have been edited to be more useful to providers:

 

MS-DRG 031: Ventricular Shunt Procedures with MCC
MS-DRG 052: Spinal Disorders and Injuries with CC/MCC
MS-DRG 054: Nervous System Neoplasms with MCC
MS-DRG 061: Acute Ischemic Stroke with Use of Thrombolytic Agent with MCC
MS-DRGs 094, 095, 096, 867, 868, 869: Cardiovascular Diseases
MS-DRGs 100, 101: Seizures
MS-DRGs 102, 103: Headaches
MS-DRGs 113, 114, 115, 116: Eye Procedures
MS-DRGs 129, 130, 131, 132, 134, 135, 136, 137, 138, 139: Ear, Nose, Mouth & Throat Procedures
MS-DRG 146: Ear, Nose, Mouth and Throat Malignancy with MCC
MS-DRG 147: Ear, Nose, Mouth and Throat Malignancy with CC
MS-DRG 177: Respiratory Infections & Inflammations with MCC
MS-DRG 178: Respiratory Infections & Inflammations with CC
MS-DRG 179: Respiratory Infections & Inflammations without CC/MCC
MS-DRGs 180, 181, 182: Respiratory Neoplasms
MS-DRGs 334, 336, 337, 338, 339, 340, 341, 342, 355, 356, 357, 417, 418, 419, 420, 421, 422, 425: Gastrointestinal Procedures
MS-DRG 414: Cholecystectomy Except by Laparoscope without C.D.E. with MCC
MS-DRG 417: Laparoscopic Cholecystectomy without C.D.E. with MCC
MS-DRG 418: Laparoscopic Cholecystectomy without C.D.E. with CC
MS-DRGs 466, 467, 468, 469, 470, 480, 483, 492, 515, 539, 540, 541: Orthopedic Procedures / Disorders
MS-DRGs 474, 475, 476: Amputations
MS-DRGs 477, 478, 479: Biopsies of Musculoskeletal System & Connective Tissues
MS-DRG 480: Hip and Femur Procedures Except Major Joint with MCC
MS-DRG 488: Knee Procedures without Principal Diagnosis of Infection with CC/MCC
MS-DRG 660: Kidney and Ureter Procedures for Non-Neoplasm with CC
MS-DRG 665: Prostatectomy with MCC
MS-DRGs 734, 735, 736, 737, 738, 739, 740, 741, 742, 743: Female Reproductive System Procedures
MS-DRG 746: Vagina, Cervix, and Vulva Procedures with CC/MCC
MS-DRG 824: Lymphoma and Nonacute Leukemia with Other O.R. Procedure with CC
MS-DRGs 837, 838, 839: Chemo with Acute Leukemia

 

Some of the above issues also include medical necessity approval for at least some of the MS-DRGs listed. Duplicates also exist in the list, as of 5 p.m. today: MS-DRGs 417, 418 and 480 each appear twice.


Also included in the list are duplicates of some previously posted MS-DRGs: 031, 356, 357, 470 and 541 (as well as 177, 178 and 179, already mentioned above).


Medical Necessity


Finally, here are the five new issues that do not list any specific MS-DRG(s):

Medical Necessity: Acute Inpatient Admission Neurological Disorders
Medical Necessity: Acute Inpatient Admission Respiratory Conditions
Medical Necessity: Cellulitis
Medical Necessity: Infections
Medical Necessity: Vagina, Cervix and Vulva Procedures


The descriptions of each of the above issues are virtually identical, giving absolutely no indication of which MS-DRGs are included in these reviews. Perhaps the safest way to interpret these issues is to include the broadest possible number of MS-DRGs.


In the case of neurological disorders, for example, we might include the entire group of diseases and disorders of the nervous system (75 MS-DRGs). For respiratory conditions, we likewise might include all diseases and disorders of the respiratory system (40 MS-DRGs).


For cellulitus, while there are only two medical MS-DRGs specifically named, there are six other surgical MS-DRGs that also refer to cellulitus and therefore should be considered as possible candidates. Finally, for vagina, cervix and vulva procedures, only two MS-DRGs exist.

 

Total More Than 200


Taken together, these five issues for medical necessity could include up to 142 MS-DRGs.


Adding those to the 94 counted in the other issues, the grand total could be as many as 236 MS-DRGs.

 

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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.

 

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