Connolly Posts First Complex Reviews By RACs

eduTrax News Service - December 3, 2009.

Connolly Healthcare posted the first Coding & DRG Validation issues approved by CMS for RAC audits, today. Twenty-five new issues were posted to their website, shortly after Noon ET. These issues are the first to be posted for Complex review, where a human must read medical records to determine the validity of the claim and reimbursement. All previously approved RAC audit issues have only been approved by CMS for Automated review, which only requires data analysis by computer. The MS-DRGs selected are not surprising, considering the findings of the RAC Demonstration project, and the potential dollar amounts that might be recouped by CMS and commissioned to the RAC.

The complete listing can be found by selecting Connolly Healthcare from this page on www.myedutrax.com.

The following 25 items were ADDED, for all States in Region C:

1. Upper Limb and Toe Amputation for Circulatory System Disorders with MCC: MS-DRG 255
2. Cirrhosis and Alcoholic Hepatitis with MCC: MS- DRG 432
3. Septicemia without Mechanical Ventilation 96+ Hours without MCC: MS-DRG 872
4. Nonextensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC - MS-DRG 989
5. Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987
6. Other Respiratory System O.R. Procedures without CC/MCC: MS-DRG 168
7. Extensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983
8. Extensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983
9. Other Respiratory System O.R. Procedures with CC: MS-DRG 167
10. Other Digestive System Diagnoses with CC: MS-DRG 394
11. Inflammatory Bowel Disease with CC: MS-DRG 386
12. Major Gastrointestinal Disorders and Peritoneal Infections without CC/MCC: MS-DRG 372
13. Other Respiratory System O.R. Procedures with MCC: MS-DRG 166
14. Major Small and Large Bowel Procedures without CC/MCC: MS-DRG 331
15. Major Small and Large Bowel Procedures with CC: MS-DRG 330
16. Major Small and Large Bowel Procedures with MCC: MS- DRG 329
17. Major Chest Procedures without CC/MCC: MS-DRG 165
18. Major Chest Procedures with MCC: MS-DRG 163
19. Major Chest Procedures with CC: MS-DRG 164
20. Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207
21. Septicemia without Mechanical Ventilation 96+ Hours with MCC: MS-DRG 871
22. Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981
23. Extensive O.R. Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982
24. Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with CC - MS-DRG 988
25. Coagulation Disorders: MS-DRG 813

All of the above include this caveat:

(At this time, Medical Necessity excluded from review).

All the above include the same description and additional notes, as follows:

Description:

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 {XXX}, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.

Provider Type Affected:   Inpatient Hospital

Date of Service: 10/01/2007 - Open

States Affected: Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

Additional Information:

Additional information can be found on the following manuals/publications:

ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E, F, G, H (2007 - 2009)

ICD-9-CM Addendums and Coding Clinics (2007 - 2009)

PIM Ch. 6.5.3, Section A-C  DRG Validation Review

It may be considered likely that the other RACs will shortly follow suit by posting similar or identical issues, in the next few weeks, which has been the history of these pages since they were first created.