RACs Post New Issues Under Medical Review

Two recovery audit contractors (RACs) for the Centers for Medicare & Medicaid Services (CMS) recently posted several new issues for claims review. DCS Healthcare will begin validating a number of additional medical severity-diagnosis related groups (MS-DRGs) reported by inpatient hospitals in its jurisdiction A. All but one of the new issues are up for medical necessity review. Jurisdiction C RAC, Connolly Healthcare, also posted several new issues for review recently. Seventeen are for MS-DRGs under medical necessity review.

The two RACs will look at claims with dates of service from Oct. 1, 2007 to the present.

DCS  – New Issues

Cardiac Defibrillator Implantation
Reviewers will validate for MS-DRG 222, 223, 224, 225, 226, 227; principal diagnosis, secondary diagnoses, and procedures affecting or potentially affecting the MS-DRG. At this time, medical necessity is excluded from review. States affected are: Connecticut, District of Columbia, Massachusetts, Maine, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont.

National Correct Coding Initiative (NCCI)
Application of the Part B NCCI (mutually exclusive and non-mutually exclusive) to ambulatory surgical centers (ASCs). Deny Column II code when billed by the same provider and same date of service as a Column I code. DCS will perform an automated review for overpayments in Connecticut, District of Columbia, Delaware, Maryland, New Jersey, New York, and Pennsylvania.

The following new issues are up for DRG coding and medical necessity validation pertaining to inpatient hospital claims in Connecticut, District of Columbia, Massachusetts, Maine, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont.

Diseases and Disorders of the Circulatory System
Reviewers will validate MS-DRGs 215, 229, 230, 232, 252-263, 265- 285, 288-290, 292-310, and 312-316 for diagnoses and procedures affecting the MS-DRG assignment. Medical records for MS DRGs 253, 254, 292, 293, 302, 308, and 312-316 will be reviewed for medical necessity.

Kidney and Urinary Tract Disorders
Reviewers will validate MS-DRGs 683, 684, 685, 686, 687, 688, 690, 695, 696, 697, 698, 699, and 700 for diagnoses and procedures affecting the MS-DRG assignment. Medical records for MS DRGs 683 and 684 will be reviewed for medical necessity.

Musculoskeletal Disorders
Reviewers will validate MS-DRGs 539, 540, 541, 545, 546, 547, 548, 549, 550, 551, 552, 553, 554, 555, 556, 557, 558, 564, 565, and 566 for diagnoses and procedures affecting the MS-DRG assignment. Medical records for MS DRGs 551 and 552 will be reviewed for medical necessity.

Nervous System Disorders
Reviewers will validate MS-DRGs 052, 053, 054, 055, 056, 057, 058, 059, 060, 070, 071, 072, 073, 074, 077, 078, 079, 080, 081, 082, 083, 084, 085, 086, 087, 088, 089, 090, 091, 092, 093, 097, 098, 099, 102, and 103 for diagnoses and procedures affecting the MS-DRG assignment. Medical records for MS DRGs 056 and 057 will be reviewed for medical necessity.

Percutaneous Cardiovascular
Reviewers will validate the principal diagnosis, secondary diagnosis, and procedures that affect or can potentially affect the MS-DRG assignment, for the MS-DRGs listed. Medical records for MS DRG 249 will be reviewed for medical necessity.

Endocrine, Nutritional, and Metabolic Disorders II
Reviewers will validate MS-DRGs 616, 617,618, 619,620,621, 622, 623, 624, 637, 638, 639, 640, 641, 642, 643, 644, and 645 for diagnoses and procedures affecting the MS-DRG assignment. Medical records for MS DRG 640 will be reviewed for medical necessity.

Diseases and Disorders of Blood, Blood Forming Organs, and Immunological Disorders
Reviewers will validate MS-DRGs 799, 800, 801, 802, 803, 804, 808, 809, 810, 811, 812, 813, 814, 815, and 816 for diagnoses and procedures affecting the MS-DRG assignment. Medical records for MS DRG 811 will be reviewed for medical necessity.

Gastro Intestinal Disorders
Reviewers will validate MS-DRGs 232, 333, 334, 338, 339, 340, 341, 342, 343, 344, 345, 346, 347, 348, 349, 368, 369, 370, 374, 375, 376, 377, 378, 379, 380, 381, 382, 383, 384, 385, 386, 387, 388, 389, 390, 391, 392, 393, 394, and 395 for diagnoses and procedures affecting the MS-DRG assignment. Medical records for MS DRGs 391 and 393 will be reviewed for medical necessity.

Respiratory
Reviewers will validate the principal diagnosis, secondary diagnosis and procedures that affect or can potentially affect the MS-DRG assignment, for the MS-DRGs 175, 176, 179, 180, 181, 182, 183, 184, 185, 186, 187, 188, 190, 191, 192, 194, 195, 196, 197, 198, 199, 200, 201, 202, 203, 204, 205, 206, and 208 for diagnoses and procedures affecting the MS-DRG assignment. MS- DRGs 190, 191, and 192 will be review for medical necessity.

Descriptions of these issues and links to reference materials are available on DCS Healthcare’s website.

Connolly Healthcare – New Issues

Pharmacy Supply and Dispensing Fees
Pharmacy supply and dispensing fees when billed and paid to a durable medical equipment (DME) supplier should be accompanied by an oral anti-cancer, oral anti-emetic, immunosuppressive drug, or inhalation drug. The absence of the drug billed on the same service date or a denial of the drug represents an overpayment. Claims selected for audit are verified to be allowed paid claims, not adjusted, cancelled, or denied. This affects DME suppliers who bill CIGNA Government Services.

Date of Death
Medicare does not pay for services or equipment after the beneficiary’s death date. This new issue affects DME suppliers who bill CIGNA.

Duplicate Claims
Exact duplicate data fields submitted for physician (carrier) claims for the same service, same member, and same service date (not including interim billing or corrected claims) resulting in duplicate payments.

The following are medical necessity issues for review:

  • Kidney and UTI – MS DRG 689
  • Other Digestive System Diagnosis – MS DRG 393
  • Other Vascular Procedures – MS DRG 253 and 254
  • Percutaneous Cardiac Procedures – MS DRG 249
  • Renal Failure – MS DRG 682, 683, and 684
  • Syncope and Collapse – MS DRG 312
  • Red Blood Cell Disorder – MS DRG 811
  • TIA – MS DRG 069
  • Chest Pain – MS DRG 313
  • Heart Failure and Shock – MS DRG 291, 292, and 293
  • Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders with MCC – MS DRG 391
  • COPD – MS DRG 190, 191, and 192
  • Nutritional and Miscellaneous Metabolic Disorders – MS DRG 640
  • Circulatory System Disorders – MS DRG 314, 315, and 316
  • Degenerative Nervous System Disorders – MS DRG 056 and 057
  • Atherosclerosis – MS DRG 302
  • Cardiac Arrhythmia – MS DRG 308
  • Medical Back Problems – MS DRG 551 and 552

Descriptions of these issues and links to reference materials are available on Connolly Healthcare’s website.

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