DCS Posts News Issues Under RAC Review

DCS Healthcare, recovery audit contractor (RAC) for Region A, posted 11 newly approved audit issues on its website mid-August. Unlike its counterpart, CGI Federal, none of the new issues include medical necessity review. Nine of the new issues are for medical severity-diagnosis related groups (MS-DRGs), another also affects inpatient claims and another affects durable medical equipment (DME) suppliers.

DCS will begin audits for the following new issues:

Certified Inpatient Coder CIC

MS-DRG Validation for Major Chest Procedures

Reviewers will validate for MS-DRG 163, 164, 165, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS-DRG.

MS-DRG Validation for Extensive OR Procedure

Reviewers will validate MS-DRG 981, 982 and 983 for principal and secondary diagnosis and procedures affecting or potentially affecting the MS-DRG assignment.

MS-DRG Validation for Complications of Cholecystectomy

Reviewers will validate MS-DRGs 411, 412, 413, 414, 415, 416, 417, 418, and 419 for principal and secondary diagnoses and procedures affecting or potentially affecting the MS-DRG assignment.

MS-DRG Validation for Craniotomy and Endovascular Intracranial Procedures

Reviewers will validate MS-DRG 025, 026, and 027 for principal and secondary diagnosis and procedures affecting or potentially affecting the MS-DRG assignment.

MS-DRG Validation for Joint Procedures

Reviewers will validate MS-DRG 462, 466, 467, 468, 469, and 470 for principal and secondary diagnosis and procedures affecting or potentially affecting the MS-DRG assignment.

MS-DRG Validation for Non-extensive OR Procedure Unrelated to Principal Diagnosis

Reviewers will validate MS-DRG 987, 988, and 989 for principal and secondary diagnosis and procedures affecting or potentially affecting the MS-DRG assignment.

Note: MS-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.

Date of Death-DME

Medicare does not typically pay for services or equipment provided after the beneficiary’s date of death.

Date of Death-Inpatient

Medicare does not typically pay for services or equipment rendered after the beneficiary’s date of death.

States under DCS jurisdiction are: Connecticut, District of Columbia, Delaware, Maine, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont.

For more information, refer to the DCS Issues Under Review webpage.

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