Health Information Management

News: RACs begin complex DRG reviews

CDI Strategies, December 10, 2009

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Facilities in 10 states could soon see medical record documentation requests for complex audits from Connolly Healthcare, CMS’ Recovery Audit Contractor (RAC) for Region C. Connolly announced the first issues approved for complex RAC review on Friday, December 4.
According to the Connolly Web site, validation of the 24 approved DRGs will occur in the following states: Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, and Texas. Connolly is not yet conducting medical necessity reviews.
Many of the DRGs Connolly plans to target are surgical, for relatively obvious reasons, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro.
A patient may undergo a procedure for a variety of different purpose, so providers would group an admission to a particular DRG based on the combination of the principal diagnosis, any present accompanying additional diagnosis (i.e., CCs or MCCs), and the principal procedure, McCall explains. Therefore, if the provider reports an incorrect code as the principal diagnosis, the assigned DRG may not be correct.
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. Look for January 2010 issue of the CDI Journal for complete analysis.

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