Newly Approved Medical Necessity Reviews by RACs
CGI Federal, the CMS RAC for Region B posted approvals for review of both Medical Necessity and DRG Validation for some 29 DRGs since last Thursday, August 12, 2010.
Half of the top 20 DRGs nationwide were included. Click here to jump down to the list.
Our subtitle above calls these “Newly Approved,” instead of “New.” Why did I use that phrase? Why not just say “new”? Well, because that’s not quite accurate, and it seems that CMS and CGI don’t consider all of them to be “new” issues. Are you surprised that a word like “new” is not well defined?
This little video snippet should help you recall recent public debate about what the word “is” means.
I’ve had “debates” like that, on occasion, and I’ve always wanted to ask the person debating with me, “How many moons are in your night sky?” Of course, some words change definitions over time, or just mean different things to different people. Small words should be easy to define, though, don’t you think?
Anyway, keep this in mind as you read on, because there does not seem to be a consensus in our industry on what the word “new” means.
More about this later…
A Valid “New” Concern for Providers
The morning after the “newly approved” medical necessity issues were first posted by CGI, I spoke with the a RAC Team Leader for a hospital system with hospitals in several states. Even though this system has no hospitals in Region B, I know this person as a keen observer of all the RAC activities, and we often talk about the impact of the RACs. “We heard from our state hospital association that Region B would be the first to post some issues for medical necessity, and that it would happen this week,” they told me. “So, this wasn’t really a surprise. But this marks a new phase for the RACs, and we are concerned about what’s on the list.”
50% of Top 20 DRGs Now Approved
A quick analysis of the list proves that provider concerns are quite valid – of the top 20 DRGs for FY2009, 10 made this new list. Therefore, perhaps half of the top 20 DRGs in any facility either are now or soon will be targets of RAC reviews for medical necessity; and remember, they were already likely targets for reviews of physician admission orders, DRG validation, and the coding for principal and secondary diagnoses.
The First “New” DRGs Approved for Medical Necessity
Now, let me explain a small caveat, about the word “new”: some of the DRGs approved for Medical Necessity are truly “new” issues, as those DRGs have never appeared on the (CGI) list before; while other DRGs were already approved for DRG Validation, but have now been “newly approved” for Medical Necessity review, as well.
So now, here is a list of six (6) issues with nine (9) DRGs never before posted on the CGI website, but now are posted as approved for review of both Medical Necessity and DRG Validation. To see the full detail, as posted by CGI, follow the links:
(Note: to see the details, you will need to login to the eduTrax main site — Registration is still Free.)
- MSDRG 253, 254: Other Vascular Procedures w CC, w/o CC/MCC
- MSDRG 302: Atherosclerosis w MCC
- MSDRG 312: Syncope & Collapse
- MSDRG 313: Chest Pain
- MSDRG 314, 315, 316: Other Circulatory System Diagnoses
- MSDRG 811: Red Blood Cell Disorders w MCC
There was also one DRG added for the first time, but only approved for DRG Validation:
Ok, but that’s still only nine of the DRGs. Where are the others posted on the site?
Twenty More DRGs with Medical Necessity “Newly Approved”
The other 20 DRGs now approved for Medical Necessity review were all listed previously for DRG Validation in a total of 12 issues, dating back to December, 2009, among the first complex reviews posted by CGI. These 20 DRGs were not listed as “new” issues, but were simply “called out” as approved for Medical Necessity by renaming those previously approved issues.
The 12 issues with some DRGs newly approved for medical necessity review are as follows:
- MSDRG 056, 057, 069: Nervous System Disorders
- MSDRG 190, 191: Chronic Obstructive Pulmonary Disease
- MSDRG 192: Respiratory
- MSDRG 249: Percutaneous Cardiovascular Procedures
- MSDRG 291, 292, 293: Heart Failure & Shock
- MSDRG 308: Cardiac arrhythmia & conduction disorders
- MSDRG 391: Esophagitis gastroenteritis and misc digest disorder
- MSDRG 393: GI Disorders
- MSDRG 551, 552: DRG Validation for Musculoskeletal Disorders
- MSDRG 640: Nutritional & Metabolic Disorders
- MSDRG 682, 683, 684: Renal Failure
- MSDRG 689: Kidney & Urinary Tract Infections
Confused yet?
Why Not List All Those As “New Issues”?
Why indeed! NOW, with the lists out of the way, let’s finally discuss why I even bring this up, and why it really will matter to providers — at least the ones who are trying to keep up with what the RACs are doing.
“New” Issues Must Be Posted by the RAC
According to the RAC Statement of Work, before a RAC can begin sending out requests for documentation to conduct complex reviews, or even demand letters for automated reviews already completed, the RAC must first win the approval of any audit issues from CMS, and then they must post all those approved issues on a public web site.
Last August, we all began watching those websites ominously take form and grow by leaps and bounds, in some cases, with the addition of more and more “new,” approved issues. We were curious to see the formats that the RACs were using, as each seemed to have their own private format for posting the issues.
Why Not All Use the Same Format?
Because they don’t have to. The RAC Statement of Work actually says NADA about what the format of these websites should be, and how “approved issues” should be “posted” on the sites. Whence, each RAC has their own interpretation of how to “post” their “new,” dare we say “newly minted,” approved issues.
To be sure, Medical Necessity review was never approved by CMS for a RAC before August 6, (now there’s an ominous date for you) and no issue approved for medical necessity review has being posted on any RAC website before August 11. However… now that such approvals have been garnered, and such posts have been made, at least some of said posts have been done in a manner that could be described as… well… obscure.
I call them obscure because some of these posts wind up as simple “edits” instead of “new” line items.
The method that CGI has chosen for posting approvals of Medical Necessity reviews is either of two methods:
- post it as a new issue if the DRG is not already on the list; or
- merely change the name or title of the previously approved issue that lists the DRG, to include Medical Necessity review for one or more of the already approved DRGs in that issue.
So, some 20 of the 29 DRGs wound up “sprinkled” within 12 older issues, and simply had their titles “edited” instead of appearing as “new” line items in the list.
Why does this matter? Because the RACs can now post changes to their list of approved issues, without notice. Of course, they didn’t have to notify any of the providers before, but the lists seemed to do that, after a fashion – a form of notifying providers of what’s being reviewed, what to expect from the RACs.
Since the lists first appeared, many of us were thinking that we could watch the RAC websites and see the “new issues” get posted, from week to week; hoping we could simply sort the list (somehow) by date posted, and we’d know if there was anything “new” on the list or not.
“We all” were wrong. It would seem that “new” doesn’t have the same meaning, as we now see with the way a “new” review approach (medical necessity) is embedded in the original posted issue. Keep in mind that there is no reason to think that the other RACs will not adopt this same approach, also. Instead of posting “new” issues for Medical Necessity, they may simply rewrite the descriptions of their “old” issues, just as CGI has done.
Anyway, more “new”…oops… “edited” issues can be expected, any day. They’ll just be harder to track now, because we’ll have to read every issue, every day, to see what changed.
Oh, and by the way, I only see one moon in my night sky — how about you?
The RAC contracted for the southern and southeastern states, Connolly Healthcare, continues to post new automated issues concerning dose-versus-units-billed, further proving that injections and infusions is a major target for RAC review, and a continuing concern for provider reimbursement, especially for physicians and outpatient settings.
In the continuing posting of issues, the RAC contracted for the upper midwestern states, CGI Federal, has now joined Connolly Healthcare in its posting of an issue that can possibly recoup all Medicare Part A charges for an inpatient claim, and still not even touch the dreaded issue of Medical Necessity.
recovery audit contractor
