Health Information Management

Healthcare News: RAC begins complex DRG validation audits

JustCoding News: Inpatient, December 9, 2009

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by Andrea Kraynak, CPC-A

Connolly Healthcare announced on December 4 the first issues approved for complex RAC review, so 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.

According to the Connolly Web site, the 24 approved DRG validation issues are: 

  • MS-DRG 163. Major chest procedures with MCC
  • MS-DRG 164. Major chest procedures with 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

Editor’s note: It has been brought to our attention that one of the newly listed issues (MS-DRG 372. Major gastrointestinal disorders and peritoneal infections without CC/MCC) may contain an error as it is listed on the Connolly’s RAC Web site. The description for MS-DRG 372 is actually “Major gastrointestinal disorders and peritoneal infections with CC,” whereas the description provided applies to MS-DRG 373. It is unclear at this time which of the two, either the DRG number or description, has actually been approved for review. 

Connolly has also provided descriptions of each of the new issues, along with references for providers who are looking to find more information on any of the topics.

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.

In other RAC news, CMS has published new documentation request limits for RAC DRG validation audits in 2010.

CMS changed the limits to a maximum of 200 record requests per campus (not national provider identifier) per 45-day period–at least through March 2010. Beginning in April providers or suppliers who bill in excess of 100,000 claims to Medicare may receive up to 300 requests per campus.

In addition, CMS will allow the RACs to request permission on a case-by-case basis to exceed the cap beginning in July 2010.

For more information, visit the CMS RAC Web site.

Editor’s note: Andrea Kraynak, CPC-A, is senior managing editor of HCPro’s The RAC Report, Medical Records Briefing, and HIM Connection. Contact her at akraynak@hcpro.com.

This article was adapted from those originally published on the Revenue Cycle Institute blog.



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