Case Management

CMW Mentor moment: RAC begins complex DRG validation audits

Case Management Weekly, December 9, 2009

The following article is an excerpt from HCPro’s resource for hospital case managers—www.CaseManagementMentor.com—a free blog dedicated to connecting hospital case managers to industry pacesetters, peers, and best practices. This post was adapted from an article on the Revenue Cycle Institute Web site.

Connolly Healthcare has announced the first issues approved for complex RAC review, and providers in several RAC Region C states could begin seeing medical record documentation requests at any time. Connolly is not yet reviewing for medical necessity.

The DRG-validation issues are approved for the following states: Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, and Texas.

The Connolly Web site identifies 24 approved DRG validation issues:

  • MS-DRG 163. Major chest procedures with major complication/comorbidity (MCC)  
  • MS-DRG 164. Major chest procedures with complication/comorbidity (CC) 
  • MS-DRG 165. Major chest procedures without CC/MCC 
  • MS-DRG 166. Other respiratory system OR procedures with MCC 
  • MS-DRG 167. Other respiratory system OR procedures with CC 
  • MS-DRG 168. Other respiratory system OR procedures without CC/MCC 
  • MS-DRG 207. Respiratory system diagnosis with ventilator support 96+ hours 
  • MS-DRG 255. Upper limb and toe amputation for circulatory system disorders with MCC. 
  • MS-DRG 329. Major small and large bowel procedures with MCC 
  • MS-DRG 330. Major small and large bowel procedures with CC 
  • MS-DRG 331. Major small and large bowel procedures without CC/MCC 
  • MS-DRG 372. Major gastrointestinal disorders and peritoneal infections without CC/MCC
  • MS-DRG 386. Inflammatory bowel disease with CC 
  • MS-DRG 394. Other digestive system diagnoses with CC 
  • MS-DRG 432. Cirrhosis and alcoholic hepatitis with MCC 
  • MS-DRG 813. Coagulation disorders 
  • MS-DRG 871. Septicemia without mechanical ventilation 96+ hours with MCC 
  • MS-DRG 872. Septicemia without mechanical ventilation 96+ hours without MCC 
  • MS-DRG 981. Extensive OR procedure unrelated to principal diagnosis with MCC 
  • MS-DRG 982. Extensive OR procedure unrelated to principal diagnosis with CC 
  • MS-DRG 983. Extensive OR procedure unrelated to principal diagnosis without CC/MCC 
  • MS-DRG 987. Nonextensive OR procedure unrelated to principal diagnosis with MCC 
  • MS-DRG 988. Nonextensive OR procedure unrelated to principal diagnosis with CC 
  • MS-DRG 989. Nonextensive OR procedure unrelated to principal diagnosis without CC/MCC

Read the rest of this post, or share your thoughts on this topic.

Browse more blog posts at www.CaseManagementMentor.com.

Most Popular