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Complex RAC Reviews Have Begun

The first Coding & DRG Validation issues approved for RAC audits have been posted on the Connolly website. The MS-DRGs selected are not surprising, given the history of the RAC Demonstration findings, and the dollar potential for take-backs.

To see the complete original listings, visit this page on eduTrax.

Are you ready? Really? Note the emphasis on “attending physician description (documentation)” in the posts by Connolly.

In the next few days, we will post some commentary on what we would advise providers to be looking into, in preparation for the doubtless onslaught of record requests and subsequent denials that this event precedes.

The following 25 items were ADDED, for all States in Region C:

1. Upper Limb and Toe Amputation for Circulatory System Disorders with MCC: MS-DRG 255
2. Cirrhosis and Alcoholic Hepatitis with MCC: MS- DRG 432
3. Septicemia without Mechanical Ventilation 96+ Hours without MCC: MS-DRG 872
4. Nonextensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC – MS-DRG 989
5. Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987
6. Other Respiratory System O.R. Procedures without CC/MCC: MS-DRG 168
7. Extensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983
8. Extensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983
9. Other Respiratory System O.R. Procedures with CC: MS-DRG 167
10. Other Digestive System Diagnoses with CC: MS-DRG 394
11. Inflammatory Bowel Disease with CC: MS-DRG 386
12. Major Gastrointestinal Disorders and Peritoneal Infections without CC/MCC: MS-DRG 372
13. Other Respiratory System O.R. Procedures with MCC: MS-DRG 166
14. Major Small and Large Bowel Procedures without CC/MCC: MS-DRG 331
15. Major Small and Large Bowel Procedures with CC: MS-DRG 330
16. Major Small and Large Bowel Procedures with MCC: MS- DRG 329
17. Major Chest Procedures without CC/MCC: MS-DRG 165
18. Major Chest Procedures with MCC: MS-DRG 163
19. Major Chest Procedures with CC: MS-DRG 164
20. Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207
21. Septicemia without Mechanical Ventilation 96+ Hours with MCC: MS-DRG 871
22. Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981
23. Extensive O.R. Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982
24. Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with CC – MS-DRG 988
25. Coagulation Disorders: MS-DRG 813

We note that Septicemia, while only listed once above, is bound to be a major target area, due to its very nature.

No Medical Necessity Reviews, As Yet

All of the above include this caveat:

(At this time, Medical Necessity excluded from review).

Of course, all this means is that such review is postponed until Jan 1, 2010, when such reviews can be conducted. Anything a provider must submit before then has direct potential to be audited for exactly that — Medical necessity — after January 1.

Sparse Descriptions, As Yet

All the above are described and listed with similar notes, as follows:

Description:

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}, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.

Provider Type Affected:   Inpatient Hospital

Date of Service: 10/01/2007 – Open

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

Additional Information:

Additional information can be found on the following manuals/publications:

ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H (2007 – 2009)

ICD-9-CM Addendums and Coding Clinics (2007 – 2009)

PIM Ch. 6.5.3, Section A-C  DRG Validation Review

Other Changes on the Connolly List

The following item CHANGED:

Once in a lifetime procedures

The following lines were ADDED to the Description:

Claims with modifier-58 will be excluded from your audit with dates of service starting 1/1/09.  Starting 1/1/09 this code was allowed to be billed more than once if the provider used the modifier.

Also, states were ADDED to the list of States Affected. The list now includes:

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

Stay tuned, as the situation unfolds.

recovery audit contractor

Tags: CMS, complex review, Connolly Healthcare, rac, recovery audit contractor

This entry was posted on Thursday, December 3rd, 2009 at 10:51 pm and is filed under From the road..., Medical Coding News. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.