Updated on: January 31, 2013

Region D RAC Posts 14 Issues Reviewing Medical Necessity

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Original story posted on: September 27, 2011

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Part A providers in Recovery Audit Contractor (RAC) Region D have 14 new issues to worry about.

HealthDataInsights, the RAC for the 17 states and three territories in Region D, posted the acute care hospitalization issues and will review the medical necessity of those services.

DCS Healthcare Services, the RAC in Region A, posted one issue for Maryland Part A providers.

Part A

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review – MDC 5 conditions of the circulatory system (medical) MS-DRGs 286, 287, 288, 289, 290, 291, 292, 293, 299, 300, 301, 302, 303, 304, 305, 308, 309, 310, 311, 312, 313, 314, 315, 316

9/19/11

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.

Social Security Act sections 1886(d), 1814(b)(3); CMS Pub. 100-08, chapter 13; CMS Pub. 100-02, chapter 1; CMS Pub. 100-04, chapter 3; Pepper Reports, OIG Reports A-01-10-01000, A-03-00-00007, OAI-05-88-00730; Change request 3200, transmittal 156; MLN Article #MM3200; Admissions of less than 24 hours policy – Maryland

Acute inpatient hospitalization – cardiac valve and other major cardiothoracic procedures with cardiac cath with CC (DRG 217)

9/8/11

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, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – cardiac valve and other major cardiothoracic procedure with cardiac cath with MCC (DRG 216)

9/8/11

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, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – pneumothorax without CC/MCC (DRG 201)

9/8/11

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, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – deep vein thrombophlebitis with CC/MCC (DRG 294)

9/8/11

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, chapters 1 and 6; CMS Pub. 100-08, chapter 6

 


 

Acute inpatient hospitalization – skin ulcers with MCC (DRG 592)

9/8/11

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, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – cardiac congenital and valvular disorders without MCC (DRG 307)

9/8/11

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, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – cardiac congenital and valvular disorders with MCC (DRG 306)

9/8/11

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, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – pleural effusion with MCC (DRG 186)

9/8/11

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, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – major chest trauma without CC/MCC (DRG 185)

9/8/11

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, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – major chest trauma with CC (DRG 184)

9/8/11

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, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – pleural effusion with CC (DRG 187)

9/8/11

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, chapters 1 and 6; CMS Pub. 100-08, chapter 6

 


 

Acute inpatient hospitalization – pneumothorax with CC (DRG 200)

9/8/11

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, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – pneumothorax with MCC (DRG 199)

9/8/11

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, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – pleural effusion with CC/MCC (DRG 188)

9/8/11

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, chapters 1 and 6; CMS Pub. 100-08, chapter 6

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 healthcare business, regulation and reimbursement.

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KLong@decisionhealth.com

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