February 10, 2010

Trend for High Dollar Claims Continues as Connolly Posts 19 New DRG Validation Issues

By

ernieConnolly Healthcare, the RAC for Region C, has posted 19 new approved issues for Complex Review on their RAC Issues page.


The new issues were posted on Monday, February 8, 2010. The listed issues include only single MS-DRGs, but are still not listed in any discernable order. All of the new issues are approved for Complex Review in all thirteen of the Region C states (AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX), using DRG Validation techniques, as outlined in the Medicare Program Integrity Manual, Chapter 6.5.3.


Top Ranked, High Dollar DRGs Added


It comes as no surprise that many of the DRGs added to the list are aimed at high-dollar claims, given Connolly's demonstrated proclivity to review high-dollar DRGs. You can see our recent analysis published in RAC Monitor just last week, HERE.


We note a couple of interesting facts about these new issues:

  • Of the 52 DRGs with Relative Weights greater than 5.0, Connolly just added four (4), bringing their total to eight (8) of the highest paying DRGs being reviewed by Connolly;

  • Six(6) of the 19 new issues are ranked (by number of discharges) in the top 100 DRGs nationwide;

  • Fifty eight percent of the 19 new issues have Relative Weights greater than 2.0 compare that to only 26 percent of all DRGs, showing a very definite continuing preference to review high-dollar claims.


Medical Necessity Still Excluded, At This Time


None of the posted issues are approved for review of Medical Necessity, but still include the caveat, "at this time." To date, none of the 550+ DRG Validations issues approved for all the RACs have included review of Medical necessity. However, the RACs have now stacked the deck in their favor, so to speak.


What Happens When Medical Necessity is Approved for Review?


Consider these facts about what the situation will be like, once medical necessity is finally approved by CMS for review by RACs: 

  • RACs will already have many records in hand being reviewed for DRG Validation;
  • DRG Validation actually does in fact involve review of medical necessity, per CMS instructions in the PIM (see Chapter 6.5.4, the one they haven't mentioned, so far);
  • RACs won't even have to make additional ADRs (Additional Documentation Requests) to do medical necessity reviews for records they already have in hand;
  • Medical necessity reviews for all existing DRG Validation issues are likely to be approved in short order, since the CMS RAC Review Phase-In Strategy calls for this in calendar 2010.
  • Records already in hand do not count toward the ADR Limits just approved by CMS -- so the RAC can issue more ADRs, every 45 days.

In other words, when medical necessity is approved, the RACs will already have done those reviews, and will likely be even better prepared to do more, immediately.


Three States Added to Previously Posted Issues


Previously, Connolly posted most of their DRG Validation issues as approved for review in only 10 of their 13 states. However, on February 2, the last three states under their purview - Arkansas, Louisiana and Mississippi- were added to the states affected lists for all previously approved DRG Validation issues, now bringing them fully under the magnifying glass of the RAC.


More Useful Lists Are Available


Several providers have told us that they have sent written requests to Connolly to make their approved issues list more "user-friendly."  Connolly's response, we are told, was "we'll take it under consideration."  Also, we've heard that CMS has responded to similar provider requests, saying that the format of the published lists is "not included in the Statement of Work" - meaning, we suppose, the formats are not specified by CMS, and therefore the RACs are able to provide the lists in whatever format they decide to use. The result, of course, is that each RAC uses a completely different format.


We think it is not very likely that those formats will become more usable. After all, since the RACs only get paid if THEY find erroneous payments, it behooves them to do as little as possible to help the providers find the errors beforehand. If a provider finds an error in an internal audit and self-discloses those errors to CMS before a RAC finds those same errors, then the RAC gets nothing.


Nevertheless, the Statement of Work does require the RACs to post all their approved issues on public Web pages, before they can begin sending out records requests for demand letters. They do now publish such pages, and links to all the RAC New Issues Pages can be found here.


For more useful lists, see below.


Use the links below to see details of the newly posted issues, in our database (Note: this list appears here in the reverse order as posted by Connolly):


1

MS-DRG 208: Respiratory System Diagnosis with Ventilator Support

2

MS-DRG 038: Extracranial Procedures with CC

3

MS-DRG 227: Cardiac Defibrillator Implant without Cardiac Catheterization without MCC

4

MS-DRG 240: Amputation for Circulatory System Disorders Except Upper Limb and Toe with CC

5

MS-DRG 242: Permanent Cardiac Pacemaker Implant with MCC

6

MS-DRG 957: Other O.R. Procedures for Multiple Significant Trauma with MCC

7

MS-DRG 344: Minor Small and Large Bowel Procedures with MCC

8

MS-DRG 488: Knee Procedures without Principal Diagnosis of Infection with CC/MCC

9

MS-DRG 533: Fractures of Femur with MCC

10

MS-DRG 216: Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with MCC

11

MS-DRG 460: Spinal Fusion Except Cervical with MCC

12

MS-DRG 248: Percutaneous Cardiovascular Procedure with Non Drug-Eluting Stent with MCC or 4+ Vessels/Stents

13

MS-DRG 222: Cardiac Defibrillator Implant with Cardiac Catheterization with Acute Myocardial Infarction/Heart Failure/Shock with MCC

14

MS-DRG 201: Pneumothorax without CC/MCC

15

MS-DRG 945: Rehabilitation with CC/MCC

16

MS-DRG 470: Major Joint Replacement or Reattachment of Lower Extremity without MCC

17

MS-DRG 885: Psychoses

18

MS-DRG 291: Heart Failure and Shock with MCC

19

MS-DRG 189: Pulmonary Edema and Respiratory Failure


To find a list of all of Connolly's posted issues, go HERE.  (Registration required.)


A version of these lists that can be downloaded (as a CSV file) is coming soon. Stay tuned!


About the Author


Ernie de los Santos is the chief information officer at 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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