Health Information Management

Healthcare News: RACs update lists of approved audit issues

JustCoding News: Outpatient, January 27, 2010

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by James Carroll

Editor’s note: The information in this article was the most current available to us at the time of publication. Please check your Recovery Audit Contractor’s (RAC) Web site to get the most up-to-date list of approved issues, as they may update on a daily basis.

RACs have been particularly active over the last few weeks. One RAC removed an item from its list of issues approved for review, which is fairly unusual, while several added a significant number of new issues. The following is just a sampling of the most recent updates that RACs posted during the last week.

On January 25, CGI removed medically unlikely edits (MUEs) from its CMS-approved list for providers in all Region B states. On that same day, CGI added the following new issues for non-medical necessity DRG-validation inpatient claims to its CMS-approved list: 

  • Acute respiratory failure: MS-DRG 189 
  • Cardiac defibrillator implant with cardiac catheterization without acute myocardial infarction/heart failure/shock with MCC
  • Cardiac valve and other major cardiothoracic procedures with CC or MCC
  • Carotid artery stent and extracranial procedures with CC or MCC
  • Coronary bypass with percutaneous transluminal coronary angioplasty/cardiac catheterization with MCC
  • Cranial/facial procedures with CC or MCC
  • Craniotomy, endovascular and intracranial vascular procedures with CC or MCC
  • Disorders of the eye, infections and procedures (orbital and interocular) with CC or MCC
  • Major cardiovascular thoracic aortic aneurysm repair procedures with CC or MCC
  • Major chest procedures with CC or MCC
  • Major head and neck procedures with CC or MCC
  • Other cardiothoracic procedures with CC or MCC
  • Other ear, nose, mouth and throat operating room procedures with CC or MCC
  • Percutaneous cardiovascular procedure with drug-eluting or non-drug eluting stent with MCC or four-plus vessels/stents
  • Peripheral/cranial nerve and other nervous system procedures with CC or MCC
  • Tracheostomy MS-DRG validation—overpayment
  • Tracheostomy MS-DRG validation—underpayment
  • Ventricular shunt procedures with CC or MCC

Access the CGI Web site to view its complete list of approved audit issues.

In addition, on January 20 DCS Healthcare, the RAC for Region A, added three new MS-DRG validation issues to its list approved for review:

  • MS-DRGs with ventilator support of 96+ hours. 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. Reviewers will validate for MS-DRGs 003, 004, 207, 870, 927 and 933; principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
  • MS-DRG 189, pulmonary edema and respiratory failure. 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. Reviewers will validate for MS-DRG 189, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
  • MS-DRGs for tracheostomy. 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. Reviewers will validate for MS-DRGs 003, 004, 011, 012, 013; principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.

Access the DCS Web site to view its complete list of approved audit issues.

Also, Region D RAC HealthDataInsights added the following two new issues for durable medical equipment (DME) claims to its CMS-approved list on January 19:

  • Medical supplies and home health consolidated billing. Under the Prospective Payment System (PPS), a home health agency must bill for all home health services, which includes nursing and therapy services, routine and nonroutine medical supplies, home health aide and medical social services, except DME. DME was excluded from the Balanced Budget Act established consolidated billing requirement by the Balanced Budget Refinement Act. The law requires that all home health services paid on a cost basis be included in the PPS rate. Therefore, the PPS rate will include all nursing and therapy services, routine and nonroutine medical supplies, and home health aide and medical social services.
  • Date of death. Medicare does not pay for services or equipment after the beneficiary’s date of death.

Access the HDI Web Site to view its complete list of approved audit issues.

For more expert analysis on the newly approved DRG validation issues, access the Revenue Cycle Institute Web site. To stay on top of the latest RAC-approved issues in your state, visit the “Tools” section of the Revenue Cycle Institute Web site and download the updated chart at the top of the page.

Editor’s note: James Carroll is the associate editor for HCPro’s Revenue Cycle Institute. Contact him at jcarroll@hcpro.com. This article was adapted from those originally published on the Revenue Cycle Institute blog.



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