Connolly Begins RAC Reviews of Medical Necessity
| Connolly Begins RAC Reviews of Medical Necessity |
| Written by Team eduTrax |
| Sunday, 29 August 2010 19:00 |
Same 29 MSDRGs Approved for CGI, HDIConnolly Healthcare posted approvals today for the review of medical necessity for the same 29 MSDRGs already posted earlier this month by two other Recovery Audit Contractors (RACs), as reported here previously, on August 13. Unlike the other two RACs, however, Connolly has chosen to post these approvals as “new” issues, separate and apart from previous postings of some of the same MSDRGs already approved for DRG Validation, with medical necessity excluded. The list below gives the DRGs as posted. Those with an asterisk (*) after the description are specifically noted by Connolly to include DRG Validation review: (Note: you will need to login to the eduTrax main site -- Registration is still Free.) Target: Short StaysThe descriptions posted are the most succinct and specific yet to be posted by any RAC. For medical necessity, the description reads as follows, with each code inserted as appropriate: “RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG [XXX]. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly.” (Emphasis added) For those MSDRGs approved for both Medical Necessity and DRG Validation, an additional paragraph is included after the one about medical necessity, above: “RACs WILL ALSO REVIEW documentation for DRG Validation requiring 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, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.” (Emphasis original) This description does mirror previous language used in other postings for approval of DRG Validation, except for the previous exclusion of the review of medical necessity. Some Overlap and ConfusionAgain, at the time of this writing (1:30pm ET), there appears to be some overlap for at least one MSDRG: 314. This one is listed in three (3) different posted issues on the Connolly site: Medical Necessity: Circulatory System Disorders -- lists MSDRG 314 specifically, by itself. MSDRG 314: Other Circulatory System Diagnoses W MCC -- also lists MSDRG 314 specifically, all by itself. [Edit: Issue removed, later.] MSDRG 280, 281, 282, 283, 284, 285, 288, 289, 290, 292, 293, 296, 297, 298, 299, 300, 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 311, 313, 314, 316: Cardiovascular Diseases -- includes 314 for both DRG Validation and Medical Necessity. Also, MSDRG 315 is listed twice, with the newer one an approval for Medical Necessity, but the older listing has not yet been edited to remove the phrase excluding medical necessity: MSDRG 315: Other Circulatory System Diagnoses with CC -- the older listing, excluding medical necessity. Medical Necessity: Circulatory System Disorders -- lists 314, 315 and 316, specifically for medical necessity and DRG Validation.
Plus More DRG ValidationsIn addition to the 19 new issues posted for medical necessity, Connolly posted 32 other new DRGs as approved for DRG Validation (Medical Necessity excluded at this time, except for specific cases mentioned in the descriptions): MSDRG 254: Other Vascular Procedures without CC/MCC Edits to Existing PostsPreviously listed MSDRGs with approval for only DRG Validation to the exclusion of medical necessity had been neither edited nor removed from Connolly’s list, as of Friday afternoon, August 27. However, by 9am Monday morning, August 30, some edits have begun to appear. At the time of this posting, the following edits were noted, both no longer include a phrase excluding review of Medical Necessity -- in fact, they do not mention it at all, now: MSDRG 291: Heart Failure and Shock with MCC MSDRG 253: Other Vascular Procedures with CC Unfortunately, the Connolly list includes neither the date of posting or approval of their issues, nor do they include any internal issues “numbers” as is seen on the other three RAC websites. Nothing New?So, the list is the same – I’ve begun to call it “The List of 29”, the first 29 DRGs approved for Medical Necessity. Nevertheless, I do wish to point out something I’ve not mentioned before on this site. Sixteen (16) of “The List of 29” cover six (6) complete DRG Groupings. For example, MSDRGs 682, 683 and 684 cover all the claims for Renal Failure. The same can be said for Heart Failure and Shock, MSDRGs 291, 292 and 293 – therefore, ALL the claims may be subject to review, not just the high-paying ones. Something Providers Need to Recognize:What this means is that the RACs evidently are convinced that ALL the documentation for medical necessity for these DRG groupings may be suspect. We can deduce this, because they have already found enough evidence of "not sufficient/appropriate documentation to support medical necessity" to convince the CMS New Issues Review Board that ALL those claims may be worthy of being examined, not just the higher paying ones. So, Connolly and the other RACs are not just looking for “upcoding” (where a higher paying DRG was coded in error). The worst part is, this list probably already hits most of the DRGs in the top ten list for any facility. |
