Region C RAC Adds More Issues

Connolly Healthcare, the RAC for Region C, posted 20 new DRG Validation Issues to their list of CMS-Approved audit issues, on Friday, April16. The new issues include eight (8) MS-DRGs with very high Relative Weights (which equates to high dollar reimbursements and thereby potentially high RAC fees).

Also, six (6) of the new issues have claim volumes in the top 25% of all DRGs (as measured by the number of discharges with that DRG nationwide). A high volume of discharges provides a corresponding large number of claims for the RAC to potentially audit.

Four of the new issues are for MSDRGs with Relative Weights (RW) of better than 10.0. One of them -- MSDRG 001, Heart Transplant -- has one of the highest RWs: 24.85.  A high RW produces a high dollar reimbursement, since the Relative Weight of a DRG is used to calculate a facility's payment.

The states of Virginia and West Virginia have been absent from the list of states affected or approved for any issues, until some recent changes to the lists, earlier in April. Still, not all the issues have been approved for these two states.

For the first time in the Connolly lists, a single issue was posted to include more than one DRG: MSDRGs 799, 800 and 801.

Below is the complete list, as posted on their site:

• MS-DRG 003: ECMO or Trach'y with Mech. Vent'n 96+ Hours or PxDx Except Face, Mouth &Neck w/ Major O.R.
• MS-DRG 001: Heart Transplant or Implant of Heart Assist System with MCC
• MS-DRG 005: Liver Transplant with MCC or Intestinal Transplant
• MS-DRG 332: Rectal Resection with MCC
• MS-DRG 562: Kidney Transplant
• MS-DRG 011: Tracheotomy for Face, Mouth, and Neck Diagnoses with MCC
• MS-DRG 012: Tracheotomy for Face, Mouth, and Neck Diagnoses with CC
• MS-DRG 020: Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with MCC
• MS-DRG 021: Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with CC
• MS-DRG 927: Extensive Burns or Full Thickness Burns with Mech. Vent'n 96+ Hours with Skin Graft
• MS-DRG 929: Full Thickness Burn with Skin Graft or Inhalation Injury without CC/MCC
• MS-DRG 023: Craniotomy w/ Major Device Impl./Acute Complex Cent Nerv Sys PxDx w/MCC or Chemo Implant
• MS-DRG 024: Craniotomy w/ Major Device Impl./Acute Complex Cent Nerv Sys PxDx w/o MCC
• MS-DRG 007: Lung Transplant
• MS-DRG 076: Viral Meningitis without CC/MCC
• MS-DRG 461: Bilateral or Multiple Major Joint Procedures of Lower Extremity with MCC
• MS-DRGs 799, 800, 801: Splenectomy w MCC, w CC, w/o CC/MCC
• MS-DRG 178: Respiratory Infections & Inflammations with CC
• MS-DRG 177: Respiratory Infections & Inflammations with MCC
• MS-DRG 179: Respiratory Infections & Inflammations without CC/MCC

To see the complete original listings (on the RAC websites), visit this page.

All of the above approved issues still include this caveat:

Medical Necessity Reviews, however, could be approved by CMS at any time now, since the CMS RAC Review Phase-In Strategy allows for such audits in calendar 2010.