RAC Medical Necessity Reviews Begin with 29 DRGs

CGI Posts 9 New DRGs plus 20 Previously Only Approved for DRG Validation

CGI Federal, the Recovery Audit Contractor (RAC) for CMS Region B, posted seven new issues on August 12, 2010, including their first nine (9) DRGs approved for review of Medical Necessity and DRG Validation. The RAC also added another 20 DRGs as approved for review of Medical Necessity. These 20, however, were buried within the web pages and were not listed as new issues. Instead, the "Issue Name" fields on the CGI Approved Issues pages were simply changed to note which DRGs were or were not yet approved for Medical Necessity. eduTrax will release

further analysis of these issues, shortly.

An Ever-Changing List

Previously, it was expected that the RACs would be posting "new issues" as a way of identifying newly approved review issues. Yesterday's postings, however, make it clear that at least CGI has no intention of posting medical necessity reviews as "new issues" unless the DRGs involved have never been approved/posted before.

Below are the seven new issues with 10 DRGs, 9 of them approved for Medical Necessity:

(Note: you will need to login to the eduTrax main site -- Registration is still Free.)

• MSDRG 253, 254: Other Vascular Procedures w CC, w/o CC/MCC
• MSDRG 302: Atherosclerosis w MCC
• MSDRG 312: Syncope & Collapse
• MSDRG 313: Chest Pain
• MSDRG 314, 315, 316: Other Circulatory System Diagnoses
• MSDRG 811: Red Blood Cell Disorders w MCC
• MSDRG 813: Coagulation Disorders (Medical Necessity excluded)

The other 20 DRGs now approved for Medical Necessity review were all listed previously for DRG Validation in 12 issues, dating back to December, 2009, among the first complex reviews posted by CGI. These 20 DRGs were not listed as "new" issues, but were simply "called out" as approved for Medical Necessity by renaming those previously approved issues.

The 12 issues with some DRGs approved for medical necessity review are as follows:

• MSDRG 056, 057, 069: Nervous System Disorders
• MSDRG 190, 191: Chronic Obstructive Pulmonary Disease
• MSDRG 192: Respiratory
• MSDRG 249: Percutaneous Cardiovascular Procedures
• MSDRG 291, 292, 293: Heart Failure & Shock
• MSDRG 308: Cardiac arrhythmia & conduction disorders
• MSDRG 391: Esophagitis gastroenteritis and misc digest disorder
• MSDRG 393: GI Disorders
• MSDRG 551, 552: DRG Validation for Musculoskeletal Disorders
• MSDRG 640: Nutritional & Metabolic Disorders
• MSDRG 682, 683, 684: Renal Failure
• MSDRG 689: Kidney & Urinary Tract Infections

Sortable Lists

Shortly, we will unveil a new list, showing only those issues approved for Medical Necessity review by the RACs.

To find a free complete, sortable listing of all currently posted issues, visit this page on eduTrax. (Registration required.) We recommend viewing the list, sorted by Approved Date.

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

Want An Alert?

If you would like to be notified by email whenever they do get posted, simply to the click here to subscribe for free to the eduTrax RAC New Issues Alert Service®. We post new issues, as in this article, and will send out an email notice immediately when medical necessity issues begin posting on the RAC websites.

Please Note:

The eduTrax RAC New Issues Database and Lists are currently made available at no charge, for a limited time only.