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.
