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DCS Healthcare posts new RAC issues for ambulance provider claims and DRG validation

Recovery Auditor Report, January 21, 2010

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DCS Healthcare has added a new RAC issue for ambulance provider claims to its CMS-approved list for providers in all Region A states. According to the DCS Web site, the new issue is as follows:

• Ambulance unbundled services during an inpatient hospital stay—Ambulance services should be billed to the inpatient provider for services for inpatients. Therefore, an issue may exist when a beneficiary received ambulance services during an inpatient stay, which have been billed and reimbursed under Medicare Part B.

DCS also added three new RAC issues for non-medical necessity DRG-validation inpatient claims 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.

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