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More High Dollar, High Volume DRGs

Connolly Healthcare, the RAC for Region C, posted 20 new DRG Validation Issues to their list of CMS-Approved audit issues, on Friday, April16. The list includes eight (8) MS-DRGs with very high Relative Weights (which equates to high dollar reimbursements and thereby potentially high RAC fees) and six (6) with claim volumes in the top 25% of all DRGs (providing a rather large number of claims to potentially audit).

Four (4) of the newly approved issues are for MSDRGs with Relative Weights of better than 10.0.  Such claims have high dollar reimbursements, averaging over $45,000 per claim, nationwide.

Once again, these approval/postings seems to continue a pattern previously noted. (See our posts from February 9 and March 17.)

Virgina and West Virginia Now Included

The states of Virginia and West Virginia have been absent from the list of states affected or approved for any issues, until some recent changes to the lists, earlier in April. Still, not all the issues have been approved for these two states.

The New Issues

Below are the new posted and approved audit issues for RAC Region C, including Relative Weights and FY09 Discharge Ranks:  (a low rank number relates to a large number of discharges for that DRG, nationwide)

• MS-DRG 003: ECMO or Tracheotomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R. (RW 18.27; Rank 122)
• MS-DRG 001: Heart Transplant or Implant of Heart Assist System with MCC (RW 24.85; Rank 720)
• MS-DRG 005: Liver Transplant with MCC or Intestinal Transplant (RW 10.14; Rank 713)
• MS-DRG 332: Rectal Resection with MCC (RW 4.78; Rank 297)
• MS-DRG 562: Kidney Transplant (RW 1.38; Rank 79)
• MS-DRG 011: Tracheotomy for Face, Mouth, and Neck Diagnoses with MCC (RW 4.73; Rank 476)
• MS-DRG 012: Tracheotomy for Face, Mouth, and Neck Diagnoses with CC (RW 3.03; Rank 584)
• MS-DRG 020: Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with MCC (RW 8.44; Rank 696)
• MS-DRG 021: Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with CC (RW 6.21; Rank 696)
• MS-DRG 927: Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours with Skin Graft (RW 13.74; Rank 629)
• MS-DRG 929: Full Thickness Burn with Skin Graft or Inhalation Injury without CC/MCC (RW 2.01; Rank 728)
• MS-DRG 023: Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis with MCC or Chemo Implant (RW 4.94; Rank 469)
• MS-DRG 024: Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis without MCC (RW 3.26; Rank 212)
• MS-DRG 007: Lung Transplant (RW 9.45; Rank 689)
• MS-DRG 076: Viral Meningitis without CC/MCC (RW 0.83; Rank 510)
• MS-DRG 461: Bilateral or Multiple Major Joint Procedures of Lower Extremity with MCC (RW 4.56; Rank 187)
• MS-DRGs 799, 800, 801: Splenectomy w MCC, w CC, w/o CC/MCC (RW 5.11, 2.53, 1.59; Ranks 666, 709, 620)
• MS-DRG 177: Respiratory Infections & Inflammations with MCC (RW 2.05; Rank 35)
• MS-DRG 178: Respiratory Infections & Inflammations with CC (RW 1.49; Rank 132)
• MS-DRG 179: Respiratory Infections & Inflammations without CC/MCC (RW 1.01; Rank 119)

To see the complete original listings (on the RAC websites), visit this page.

Or, to find a more useful listing of all their posted issues, visit  this page on eduTrax.  (Registration required.)

Still No Medical Necessity Reviews

All of the above approved issues still include this caveat:

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

As faithful readers know, however, Medical Necessity Reviews could be approved by CMS at any time now, since the CMS RAC Review Phase-In Strategy allows for such audits in calendar 2010.

We will shortly post further analysis, in an overview of the DRG Validations posted to date by all four RACs.