Revenue Cycle

CGI posts new RAC issues for Region B states

Recovery Auditor Report, January 21, 2010

CGI has added dozens of new RAC issues for all states in Region B, according to the CGI Web Site. The newest outpatient hospital and physician claims issue are as follows:

  • Intravenous infusion chemotherapy and non-chemotherapy – excessive units reported
  • Preadmission testing
  • Separately paid ambulance service during inpatient hospitalization review
  • Oxaliplatin
  • Medical unlikely edit
For inpatient hospital claims:
  • Hospital to hospital transfer
 For CSW providers
  • Clinical social workers during inpatient hospital
 For non-medical necessity DRG-validation inpatient claims
  • Cardiac arrhythmia and conduction disorders with MCC or with CC DRG 138, MS-DRG 308, 309
  • Chronic obstructive pulmonary disease DRG 88 MS-DRG 190, 191
  • Diseases and disorders of the respiratory system DRG 076,079 MS-DRG166,167,177,178,179
  • Esophagitis gastroenteritis and misc digest disorder w/MCC DRG 182 MS-DRG 391
  • Excisional debridement MS-DRG 463, 464, 465, 573, 574, 575, 901, 902, 903 (ICD9 86.22)
  • Extensive OR procedure unrelated to principal diagnosis DRG 468 MS-DRG 981,982,983
  • Gastroenteritis hemorrhage w/MCC wCC DRG 174,MS DRG 377,378,379
  • Heart failure and shock w/MCC, with CC, w/o CC/MCC DRG 127 MS-DRG 291, 292, 293
  • Intracaranial hemorrhage or cerebral infarction DRG 014, MS-DRG 064, 065, 066
  • Kidney and urinary tract infections w/MCC DRG 320, MS-DRG 689
  • Major joint replacement or reattachment w/MCC DRG 544 MS-DRG 469
  • Nutritional and metabolic disorders w/MCC DRG 296, MS-DRG 640
  • Renal Failure DRG 316, MS-DRG 682, 683, 684
  • Respiratory system diagnosis with ventilator support DRG 475, 565,566 MS – DRG 207, 208
  • Septicemia DRG 416, 576 MS-DRG 870, 871, 872
  • Simple pneumonia DRG 089, MS-DRG 193, 194, 195

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