Several with High Rankings, High Dollar Value
Connolly Healthcare, the RAC for Region C, posted 25 new DRG Validation Issues to their list of CMS-Approved audit issues, on Tuesday, March 16. Once again, Connolly has been approved for even more MS-DRGs with high Relative Weights (which equates to high dollar reimbursements) and high claim volumes (which equates to large number of claims to potentially audit).
Three (3) of the newly approved issues are for MSDRGs with Relative Weights of better than 5.0. Also, six(6) of the 25 new issues are ranked (by number of discharges) in the top 100 DRGs nationwide.
This latest round of approval/postings seems to continue a pattern we have previously noted here. (See our post from February 9.)
Noteably, the states of Virginia and West Virginia are still absent from the list of states affected or approved for any of these issues. The 13 states affected by these approved issues are: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas.
The List
Below are the new posted and approved audit issues for RAC Region C:
- MS-DRG 226: Cardiac Defibrillator Implant without Cardiac Catheterization with MCC
- MS-DRG 415: Cholecystectomy Except by Laparoscope without C.D.E. with CC
- MS-DRG 237: Major Cardiovascular Procedures with MCC or Thoracic Aortic Aneurysm Repair
- MS-DRG 969: HIV with Extensive O.R. Procedure with MCC
- MS-DRG 933: Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours without Skin Graft
- MS-DRG 239: Amputation for Circulatory System Disorders Except Upper Limb and Toe with MCC
- MS-DRG 934: Full Thickness Burn without Skin Graft or Inhalation Injury
- MS-DRG 243: Permanent Cardiac Pacemaker Implant with CC
- MS-DRG 246: Percutaneous Cardiovascular Procedure with Drug-Eluting Stent with MCC or 4+ Vessels/Stents
- MS-DRG 253: Other Vascular Procedures with CC
- MS-DRG 749: Other Female Reproductive System O.R. Procedures with CC/MCC
- MS-DRG 803: Other O.R. Procedures of the Blood and Blood-Forming Organs with CC
- MS-DRG 823: Lymphoma and Nonacute Leukemia with Other O.R. Procedure with MCC
- MS-DRG 315: Other Circulatory System Diagnoses with CC
- MS-DRG 617: Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders with CC
- MS-DRG 829: Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Other O.R. Procedure with CC/MCC
- MS-DRG 486: Knee Procedures with Principal Diagnosis of Infection with CC
- MS-DRG 941: O.R. Procedure with Diagnoses of Other Contact with Health Services without CC/MCC
- MS-DRG 577: Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with CC
- MS-DRG 358: Other Digestive System O.R. Procedures without CC/MCC
- MS-DRG 133: Other Ear, Nose, Mouth and Throat O.R. Procedures with CC/MCC
- MS-DRG 424: Other Hepatobiliary or Pancreas O.R. Procedures with CC
- MS-DRG 616: Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders with MCC
- MS-DRG 675: Other Kidney and Urinary Tract Procedures without CC/MCC
- MS-DRG 717: Other Male Reproductive System O.R. Procedures except Malignancy with CC/MCC
To see the complete original listings (on the RAC websites), visit this page.
Or, to find a more useful listing of all their posted issues, visit this page on eduTrax. (Registration required.)
Still No Medical Necessity Reviews
All of the above approved issues still include this caveat:
(At this time, Medical Necessity excluded from review).
We again remind everyone that Medical Necessity Reviews could be approved by CMS at any time now, since the CMS RAC Review Phase-In Strategy allows for such audits in calendar 2010.
Stay tuned, as the situation unfolds.
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