Revenue Cycle

CGI adds new DRG validation issues

Recovery Auditor Report, February 4, 2010

CGI, the RAC for Region B, has added new issues for non-medical necessity DRG-validation inpatient claims to its CMS-approved list for providers in all Region B states. According to the CGI Web site, the new issues are as follows:

  • Acute respiratory failure: MS-DRG 189
  • Cardiac defibrillator implant with cardiac catheter without AMI/HF/shock with major complication/comorbidity (MCC)
  • Cardiac valve and other major cardiothoracic procedures with complication/comorbidity (CC) or MCC
  • Carotid artery stent and extracranial procedures with CC or MCC
  • Coronary bypass with PTCA/cardiac catheter 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 OR procedures with CC or MCC
  • Percutaneous cardiovascular procedure with drug-eluting or non-drug-eluting stent with MCC or four-plus vessels/stents
  • Periph/cranial nerve and other nervous system procedure with CC or MCC
  • Tracheostomy MS-DRG validation—overpayment and underpayment
  • Ventricular shunt procedures with CC or MCC

Additionally, CGI has removed medically unlikely edits from its CMS-approved list for providers in all Region B states.

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.

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