January 7, 2010

Region D RAC Posts 530 Issues for Complex Review

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530 MS-DRGs Now Approved for DRG Validation and MS-DRG Coding Review

 

(January 8, 2010)---Health Data Insights (HDI) has posted 66 new approved issues for review on their Web site. The posting took place late Wednesday, January 6. HDI is the CMS Recovery Audit Contractor (RAC) for several states in the western US.

 

The issues posted by HDI are all for MS-DRG coding and DRG validation, but medical necessity is specifically excluded from review, at this time. The list of MS-DRGs included in the issues represent both medical and surgical cases, and totals 530 of the 747 existing MS-DRGs, or over 70 percent of all DRGs.


"Taken together, the four RACs are now approved for over 570 DRG Validation issues," reports Ernie de los Santos, chief information office for eduTrax. "However, the HDI list appears to overlap with the list recently posted by Connolly Healthcare, one of the other three RACs, leaving 530 as a true total, nationwide."


According to de los Santos, the same 530 MSDRGs listed by HDI were also approved for a second type of review: DRG Validation for Underpayment. He said HDI is the first RAC to list any issues for review for underpayment, although the RAC Statement of Work includes this kind of review as part of their contract with CMS. RACs are paid the same contingency fees (9% to 12.5%, depending on their contract with CMS) for either type of erroneous payment. However, de los Santos noted, it is expected that overpayments will be more abundant and more easily identified.


"HDI's list of approved issues groups multiple MS-DRGs together, in groups that have no medical counterpart," said de los Santos. "That is, the grouping of MS-DRGs is usually accomplished via the Major Diagnostic Categories (MDCs). MDCs are 25 mutually exclusive groups of ICD-9-CM diagnosis codes, which correspond to a single organ system or ‘cause' and are in general associated with a particular medical specialty. HDI, however, has grouped MS-DRGs coming from disparate MDCs."


The groupings by HDI appear to be done in order to list as many together in one "issue" as possible, sometimes including over 50 MS-DRGs, according to de los Santos. One of the issues posted is entitled, "DRG Validation-MDC 04 Respiratory, Underpayment," and then includes all 42 MS-DRGs in that MDC as being approved for review and DRG Validation, he noted.


"The list posted by HDI is a departure from what the other RACs have been doing on their lists, particularly Connolly Healthcare, the RAC for Region C, which is the only other RAC to post any issues approved for Complex Review, to date," de los Santos said.


For more news and analysis on this developing story, follow RACMonitor.


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Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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