CMS RACs Post Over 40 New Issues

eduTrax News Service - January 5, 2010.

Region C RAC Posts Over 40 Issues, Most for Complex Review

Focus is on DRG Validation and MS-DRG Coding, Not Medical Necessity. Yet.

Connolly Healthcare, the RAC assigned to most of the southern states, posted over 40 new approved issues on their website, during the last week of 2009. The issues mainly focus on MS-DRG coding and DRG validation, and not medical necessity. The list of MS-DRG’s included in the issues represent both medical and surgical cases. Click title to read more...

Activity by the other RACs has been minimal and all their posted issues appear to be only for Automated Review. Connolly Healthcare is the only RAC to date to post any issues for Complex Review.

Region A

DCS Healthcare, the Region A RAC (northeastern states), posted six (6) new issues for DME Suppliers on December 22, and on December 11, they posted one issue for Clinical Social Worker Service Providers. See the list of their issues here (requires login/registration), or see the DCS New Issues page here.

Region B

CGI Federal, the Region B RAC (north central states), posted no new issues in December, but did change the description of one issue, and added states to others. See the list of their issues here (requires login/registration), or see the CGI New Issues page here.

Region C

Connolly Healthcare, the RAC for Region C (south & southeast states), has been busy posting a slew of approved issues. During the closing week of 2009, they posted about 40, raising the total number of issues approved for Region C to 75. They also made some changes to a few issues already posted, sometimes adding more states affected by the issue, and sometimes making changes to the issue descriptions.See the list of their issues here (requires login/registration), or see the Connolly New Issues page here.

Region D

Health Data Insights, the Region D RAC (western states), only posted four (4) new issues for Automated Review during December. See the list of their issues here (requires login/registration), or see the HDI New Issues page here.

Database of New Issues Available

You can easily access all four RAC New Issues pages and download a RAC Jurisdiction map, here.

You can also access state-by-state lists of all the RAC New Issues there. (requires login/registration)

Medical Necessity Excluded, For Now

Currently, for every DRG Validation issue posted by Connolly, the following phrase is included in the issue title: “(At this time, Medical Necessity excluded from review).” So, for now, Medical Necessity is off the table. However, since the RAC will have these records anyway, we can assume that the RAC will gather information for later audits, once CMS approves such issues for Medical Necessity review.

Also, each of these issues has an almost identical 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], previously DRG [XXX], principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.”