Updated on: June 22, 2012

Winter Is Heating Up: Complex Reviews Are Here!

By
Original story posted on: January 5, 2010

cengle120xSanta was not the only one delivering gifts this holiday season.

 

Just before most of you started taking some well-deserved time off in late December, reports of the first sets of complex medical record documentation requests from Connolly Healthcare in Region C started surfacing in the Southeast.

 

Facilities in Alabama, Georgia, Tennessee, Texas, North Carolina and South Carolina were reporting receipts of complex RAC review letters, although they were not related to medical necessity. At this time all such issues remain excluded from any of these reviews, but stay tuned in 2010 for more on that.

 

Connolly also posted a number of new issues in December; there are 59 total DRG validation issues now listed on their issues Web site.

 

Approved DRG Validation Issues

 

The following table is a list of the current DRG validation issues posted to the Connolly Web site  (http://www.connollyhealthcare.com/RAC/pages/approved_issues.aspx) as of Jan.3.

 

MS-DRG

Issue Name

States Affected

163

Major Chest Procedures with MCC: MS-DRG 163.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

164

Major Chest Procedures with CC: MS-DRG 164.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

165

Major Chest Procedures without CC/MCC: MS-DRG 165.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

166

Other Respiratory System O.R. Procedures with MCC: MS-DRG 166.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

167

Other Respiratory System O.R. Procedures with CC: MS-DRG 167.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

168

Other Respiratory System O.R. Procedures without CC/MCC: MS-DRG 168.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

207

Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

252

Other Vascular Procedures with MCC: MS-DRG 252

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

255

Upper Limb and Toe Amputation for Circulatory System Disorders with MCC: MS-DRG 255.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

256

Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

260

Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

262

Cardiac Pacemaker Revision Except Device Replacement without CC/MCC: MS-DRG 262

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

264

Other Circulatory System O.R. Procedures: MS-DRG 264

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

329

Major Small and Large Bowel Procedures with MCC: MS- DRG 329.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

330

Major Small and Large Bowel Procedures with CC: MS-DRG 330.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

331

Major Small and Large Bowel Procedures without CC/MCC: MS-DRG 331.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

335

Peritoneal Adhesiolysis with MCC: MS-DRG 335

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

356

Other Digestive System O.R. Procedures with MCC: MS-DRG 356

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

357

Other Digestive System O.R. Procedures with CC: MS-DRG 357

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

372

Major Gastrointestinal Disorders and Peritoneal Infections with CC: MS-DRG 372.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

386

Inflammatory Bowel Disease with CC: MS-DRG 386.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

394

Other Digestive System Diagnoses with CC: MS-DRG 394.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

423

Other Hepatobiliary or Pancreas O.R. Procedures with MCC: MS-DRG 423

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

432

Cirrhosis and Alcoholic Hepatitis with MCC: MS- DRG 432.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

463

Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with MCC: MS-DRG 463

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

464

Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with CC: MS-DRG 464

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

465

Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders without CC/MCC: MS-DRG 465

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

573

Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with MCC: MS-DRG 573

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

574

Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC: MS-DRG 574

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

575

Skin Graft and/or Debridement for Skin Ulcer or Cellulitis without CC/MCC: MS-DRG 575

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

576

Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with MCC: MS-DRG 576

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

578

Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis without CC/MCC: MS-DRG 578

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

622

Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with MCC: MS-DRG 622

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

623

Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with CC: MS-DRG 623

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

624

Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC: MS-DRG 624

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

673

Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

674

Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

813

Coagulation Disorders: MS-DRG 813.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

853

Infectious and Parasitic Diseases with O.R. Procedure with MCC: MS-DRG 853

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

854

Infectious and Parasitic Diseases with O.R. Procedure with CC: MS-DRG 854

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

855

Infectious and Parasitic Diseases with O.R. Procedure without CC/MCC: MS-DRG 855

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

856

Postoperative or Posttraumatic Infections with O.R. Procedure with MCC: MS-DRG 856

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

857

Postoperative or Posttraumatic Infections with O.R. Procedure with CC: MS-DRG 857

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

858

Postoperative or Posttraumatic Infections with O.R. Procedure without CC/MCC: MS-DRG 858

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

871

Septicemia without Mechanical Ventilation 96+ Hours with MCC: MS-DRG 871.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

872

Septicemia without Mechanical Ventilation 96+ Hours without MCC: MS-DRG 872.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

876

O.R. Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

901

Wound Debridements for Injuries with MCC: MS-DRG 901

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

902

Wound Debridements for Injuries with CC: MS-DRG 902

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

928

Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

935

Nonextensive Burns: MS-DRG 935

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

939

O.R. Procedure with Diagnoses of Other Contact with Health Services with MCC: MS-DRG 939

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

940

O.R. Procedure with Diagnoses of Other Contact with Health Services with CC: MS-DRG 940

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

981

Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

982

Extensive O.R. Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

983

Extensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

987

Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

988

Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with CC - MS-DRG 988.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

989

Nonextensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC - MS-DRG 989.

Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas


The Request

 

Each claim in the Connolly request lists a rationale. Here is an example of one from a request letter:

 

DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG XXX, previously DRG XXX, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Good Cause Language: The RAC Demonstration Project (3/2005 thru 3/2008) found an overwhelming majority of errors in assignment for DRG XXX, currently MS-DRG XXX, resulting in overpayments to hospitals. The RAC identified errors in the data that could be traced to the hospitals' medical record practice. An analysis of your billing data indicates that a potential aberrant billing practice may exist for this DRG.

 

The request from Connolly itself is pretty straightforward, encapsulating all of the necessary elements to identify the correct claim:

 

1)   Request No.

2)   Claim/Ref No.

3)   Medical Record No.

4)   Begin DOS

5)   End DOS

6)   Member DOB

7)   Member

8)   Patient Control No.

9)   Member Last Name

 

Figure 1: An excerpt from a RAC complex request letter for the DRG validation rationale:

010710-engle-1

 

 

Required Documentation


In the request letter, Connolly provides a list of all the required documentation to return to it within 45 days:

1)   Face sheet

2)   Discharge summary

3)   History and physical

4)   Emergency Room records

5)   All nursing notes

6)   ER nursing notes

7)   Consultations

8)   Physician orders

9)   Therapy treatment plan and notes

10)  Physician progress notes

11)  Laboratory reports

12)  Radiology reports

13)  Operative reports

14)  Pathology reports

15)  ICD-9-CM codes submitted

16)  Physician query

17)  UB 04 or HCFA (CMS) 1500

18)  Medication administration records

 

Figure 2: An excerpt from a RAC complex request letter on the support documentation requested

010710-engle-2



Some Pointers

  • Include a copy of each original request letter along with a copy of the attached pull list/spreadsheet affixed to the additional documentation when you return requested records to the auditor. This is to ensure that all the documentation is connected to the correct claim.
  • Keep a copy to ensure that, if the auditor has questions after it receives the documentation, you have copies of your own.
  • Even if you haven't received requests yet - if Connolly is not your auditor, or you are not located in one of the states listed for a specific issue - stay on top of the published issues from all of the auditors and include them in your own preemptive-defense audit strategy. As time goes on, other auditors more than likely will have the same issues posted to their Web sites.


About the Author


Carla Engle, MBA, is a product manger for MediRegs, a Wolters Kluwer company. Her background includes more than 20 years in hospital and physician practice operations, particularly in reimbursement and billing functions. Prior to joining Wolters Kluwer recently, she was the vice president of compliance for a national revenue cycle solutions company and prior to that was in the Reimbursement Training Department with HCA.  For several years she headed up the Part A Fraud Investigation Unit for a CMS Program Safeguard Contractor (PSC) where she was successful in the prosecution of several national cases. In her revenue cycle compliance capacity, she worked with a number of clients in California and Florida with Recovery Audit Contractors (RACs) in setting up processes and appeals.

 

Contact the Author

carla.engle@wolterskluwer.com

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