RAC Medical Necessity Reviews

by admin on August 16, 2010

Last week, the Region B RAC, CGI, posted several Medical Necessity Review Issues.  All are complex reviews for inpatient hospitals for all states (IL, IN, KY, MI, MN, OH, WI).  They are as follows:

Nervous System Disorders MS-DRG 056, 057 and 069
Nutritional and Metabolic Disorders DRG 296 MS-DRG 640
Other Circulatory System Diagnoses w MCC MS-DRG 314, 315, 316
Other Vascular Procedures w CC, w/o CC/MCC MS-DRG 253, 254
Percutaneous Cardiovascular Procedures MS-DRG 249
Red Blood Cell Disorders w MCC MS-DRG 811
Renal Failure DRG 316 MS-DRG 682, 683, 684
Respiratory MS-DRG 192
Syncope & Collapse MS-DRG 312
Musculoskeletal Disorders MS-DRG 551 and 552
Kidney & Urinary Tract Infections w/MCC DRG 320 MS-DRG 689
GI Disorders MS-DRG 393
Heart Failure & Shock w/MCC, w CC and w/o CC/MCC DRG 127 MS-DRG 291, 292, 293
Esophagitis, Gastroenteritis & Misc Digestive Disorders w/MCC DRG 182 MSDRG 391
Chest Pain MS-DRG 313
Chronic Obstructive Pulmonary Disease DRG 88 MS-DRG 190, 191
Atherosclerosis w MCC MS-DRG 302
Cardiac Arrhythmia & Conduction Disorders w/MCC or w/CC DRG 138, MS-DRG 308, 309

Also, in recent weeks, several new MS-DRG Validation Issues and Approved Audit Issues have been posted for all RAC Regions.  In particular, Connolly Healthcare, the Region C RAC has added numerous outpatient drug codes for dose versus unit billing errors.  Medical necessity is still excluded at this time for all audit issues.

The CMS RAC FAQs have also been updated with helpful questions and answers that are worth looking through.  To view the FAQs, go to: http://questions.cms.hhs.gov/

We encourage you to visit our website at www.hchealthcareconsultingllc.com and access our consolidated listing of both DRG validation issues identified by region and our approved audit issues table, also identified by region.  We also strongly urge providers to review the internal policies and auditing and monitoring procedures to ensure appropriate provider documentation and accurate coding oversight. We have contracted physicians and are able to assist you with medical necessity reviews, appeals and/or RAC readiness/preparedness audits.

Previous post:

Next post: