HDI Edits Ten Issues to include Reviews of Medical Necessity for 29 DRGs
The Region D RAC, HDI, only took about a week to also garner approval to begin review of medical necessity for 29 DRGs previously approved for DRG Validation, after the Region B RAC, CGI, was approved by CMS to begin medical necessity reviews for the same DRGs, as of August 6, 2010. However, while CGI had to post six (6) new issues to their site, because those DRGs had never appeared on their site before, HDI did not have to post any new issues. Of the existing 746 MSDRGs, HDI had already posted approvals for DRG Validation of over 75% of them, and these 29 did happen to already be among their approved list.
The I’s Have It: CGI and HDI
Now two of the four RACs have approval to review medical necessity, putting 24 states under such review. We do expect that to grow in the next few days, since it took HDI only about a week to catch up to CGI, so we assume Connolly and DCS are not far behind.
Although our previous post provided lists and links to the 29 DRGs, those links and titles were created using the CGI website data. Also, that list was broken into two lists — one for “new” issues, and one for “previous” issues.
Below is a list of the ten “previous” issues that now include some approvals for medical necessity. It was created using the HDI website data, which is slightly different. To see the full detail, as posted by HDI, follow the links:
It is perhaps insignificant but notable that the first two RACs to be approved for medical necessity review also happen to have the two websites that are the most difficult to monitor for changes. Both sites are constructed in a way that requires interaction, and does not provide a simple method of capturing the data on the page, to compare to a future capture of the same page.
New Service Coming
We have resorted to creating our own software application to specifically follow and compare all the pages on these two sites. Shortly, we will announce and offer a for-fee service to notify our clients and subscribers of any changes posted to any of the RAC New Issues pages, including the details screen, in addition to our eduTrax RAC New Issues Tool Suite®.
CGI Federal, the CMS RAC for Region B posted approvals for review of both Medical Necessity and DRG Validation for some 29 DRGs since last Thursday, August 12, 2010.
Half of the top 20 DRGs nationwide were included. Click here to jump down to the list.
Our subtitle above calls these “Newly Approved,” instead of “New.” Why did I use that phrase? Why not just say “new”? Well, because that’s not quite accurate, and it seems that CMS and CGI don’t consider all of them to be “new” issues. Are you surprised that a word like “new” is not well defined?
This little video snippet should help you recall recent public debate about what the word “is” means.
I’ve had “debates” like that, on occasion, and I’ve always wanted to ask the person debating with me, “How many moons are in your night sky?” Of course, some words change definitions over time, or just mean different things to different people. Small words should be easy to define, though, don’t you think?
Anyway, keep this in mind as you read on, because there does not seem to be a consensus in our industry on what the word “new” means.
More about this later…
A Valid “New” Concern for Providers
The morning after the “newly approved” medical necessity issues were first posted by CGI, I spoke with the a RAC Team Leader for a hospital system with hospitals in several states. Even though this system has no hospitals in Region B, I know this person as a keen observer of all the RAC activities, and we often talk about the impact of the RACs. “We heard from our state hospital association that Region B would be the first to post some issues for medical necessity, and that it would happen this week,” they told me. “So, this wasn’t really a surprise. But this marks a new phase for the RACs, and we are concerned about what’s on the list.”
50% of Top 20 DRGs Now Approved
A quick analysis of the list proves that provider concerns are quite valid – of the top 20 DRGs for FY2009, 10 made this new list. Therefore, perhaps half of the top 20 DRGs in any facility either are now or soon will be targets of RAC reviews for medical necessity; and remember, they were already likely targets for reviews of physician admission orders, DRG validation, and the coding for principal and secondary diagnoses.
The First “New” DRGs Approved for Medical Necessity
Now, let me explain a small caveat, about the word “new”: some of the DRGs approved for Medical Necessity are truly “new” issues, as those DRGs have never appeared on the (CGI) list before; while other DRGs were already approved for DRG Validation, but have now been “newly approved” for Medical Necessity review, as well.
So now, here is a list of six (6) issues with nine (9) DRGs never before posted on the CGI website, but now are posted as approved for review of both Medical Necessity and DRG Validation. To see the full detail, as posted by CGI, follow the links:
Ok, but that’s still only nine of the DRGs. Where are the others posted on the site?
Twenty More DRGs with Medical Necessity “Newly Approved”
The other 20 DRGs now approved for Medical Necessity review were all listed previously for DRG Validation in a total of 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 newly approved for medical necessity review are as follows:
Why indeed! NOW, with the lists out of the way, let’s finally discuss why I even bring this up, and why it really will matter to providers — at least the ones who are trying to keep up with what the RACs are doing.
“New” Issues Must Be Posted by the RAC
According to the RAC Statement of Work, before a RAC can begin sending out requests for documentation to conduct complex reviews, or even demand letters for automated reviews already completed, the RAC must first win the approval of any audit issues from CMS, and then they must post all those approved issues on a public web site.
Last August, we all began watching those websites ominously take form and grow by leaps and bounds, in some cases, with the addition of more and more “new,” approved issues. We were curious to see the formats that the RACs were using, as each seemed to have their own private format for posting the issues.
Why Not All Use the Same Format?
Because they don’t have to. The RAC Statement of Work actually says NADA about what the format of these websites should be, and how “approved issues” should be “posted” on the sites. Whence, each RAC has their own interpretation of how to “post” their “new,” dare we say “newly minted,” approved issues.
To be sure, Medical Necessity review was never approved by CMS for a RAC before August 6, (now there’s an ominous date for you) and no issue approved for medical necessity review has being posted on any RAC website before August 11. However… now that such approvals have been garnered, and such posts have been made, at least some of said posts have been done in a manner that could be described as… well… obscure.
I call them obscure because some of these posts wind up as simple “edits” instead of “new” line items.
The method that CGI has chosen for posting approvals of Medical Necessity reviews is either of two methods:
post it as a new issue if the DRG is not already on the list; or
merely change the name or title of the previously approved issue that lists the DRG, to include Medical Necessity review for one or more of the already approved DRGs in that issue.
So, some 20 of the 29 DRGs wound up “sprinkled” within 12 older issues, and simply had their titles “edited” instead of appearing as “new” line items in the list.
Why does this matter? Because the RACs can now post changes to their list of approved issues, without notice. Of course, they didn’t have to notify any of the providers before, but the lists seemed to do that, after a fashion – a form of notifying providers of what’s being reviewed, what to expect from the RACs.
Since the lists first appeared, many of us were thinking that we could watch the RAC websites and see the “new issues” get posted, from week to week; hoping we could simply sort the list (somehow) by date posted, and we’d know if there was anything “new” on the list or not.
“We all” were wrong. It would seem that “new” doesn’t have the same meaning, as we now see with the way a “new” review approach (medical necessity) is embedded in the original posted issue. Keep in mind that there is no reason to think that the other RACs will not adopt this same approach, also. Instead of posting “new” issues for Medical Necessity, they may simply rewrite the descriptions of their “old” issues, just as CGI has done.
Anyway, more “new”…oops… “edited” issues can be expected, any day. They’ll just be harder to track now, because we’ll have to read every issue, every day, to see what changed.
Oh, and by the way, I only see one moon in my night sky — how about you?
The RAC contracted for the southern and southeastern states, Connolly Healthcare, continues to post new automated issues concerning dose-versus-units-billed, further proving that injections and infusions is a major target for RAC review, and a continuing concern for provider reimbursement, especially for physicians and outpatient settings.
The List
Below are the nine new issues, posted earlier this week. Follow the links to each one, in the eduTrax RAC New Issue Database®, which can be seen with simple free registration at myedutrax.com.
You’ve billed for it, even been paid for it. But will you get to keep the money? And you can’t take the injection back…
This is like getting an injection with a barbed needle: feels ok going in, but coming back out it hurts like <insert your favorite expletive>.
For both providers and payers, there’s no confusion about one thing: injections and infusions can be tricky to properly bill.
Instruction Available
The eduTrax® site has two excellent courses available for their paid subscribers, and these can also be purchased as downloads or CDs. Short previews are available to give you an idea of their quality and content:
Coding Injections and Infusions — reviews the recent changes to injections and infusions codes and offers guidance on correct capture of these services. (3 minute preview)
RAC Focus: Injections & Infusions — discusses why, how & where physicians must be involved, and addresses code selection based upon time and service provided. (8 minute preview)
In the continuing posting of issues, the RAC contracted for the upper midwestern states, CGI Federal, has now joined Connolly Healthcare in its posting of an issue that can possibly recoup all Medicare Part A charges for an inpatient claim, and still not even touch the dreaded issue of Medical Necessity.
The List
Below are the 15 new issues, posted last week. Follow the links to each one, in the eduTrax RAC New Issue Database®, which can be seen with simple free registration at myedutrax.com.
Three of the four RACs posted new issues recently. The Region A RAC, DCS, posted 39 new DRG Validations issues, plus an approved issue to review Evaluation & Management (E&M) codes for New Patient visits, mirroring the same issues already approved for other RACs.
Despite recent reports that issues including review of Medical Necessity have already been approved by CMS in at least one region, none of the RACs have yet to post any such approved issues.
The new issues are listed below, including links to their descriptions on eduTrax®. To see those pages, you will need to login to the eduTrax main site. Registration on the site is still free.
Region A
The RAC for Region A (DCS) posted several new issues, mostly for Automated Review:
Every wonder about what difference a Discharge Status code makes for your reimbursement? Take a look at the Transfer DRG Assistant® at the eduTrax site. The complete tool includes all DRGs, all the Discharge Codes with explanations, and can show you an estimated difference in reimbursement based upon length of stay, the DRG assigned, and the appropriate status code, which is determined by where a patient may (or may not) wind up going after discharge from your facility.
Making Your Own RAC Issues Lists?
Good luck, we know how hard it is to do. To find a complete, sortable listing of all the RACs’ posted issues, visitthis 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.
When Will Medical Necessity Reviews Begin?
No one knows but the RACs, and so far, they ain’t sayin’.
CMS May Have Already Approved Medical Necessity Reviews
During the May 5, 2010 RAC 101 Conference Call, Scott Wakefield, a CMS RAC Project Manager for Region B stated that providers may begin to receive RAC medical necessity reviews “within the next month or so.” According to one observer, he seemed somewhat surprised that no such reviews have been posted by the RACs, as yet, and intimated that such issues had already been approved.
Meanwhile, in the past two weeks, the RAC have all posted new issues, but none with medical necessity reviews approved.
While the RAC for Region A (DCS) only posted one new issue, it is not exactly inconsequential:
MS-DRG Validation for HIV — Reviewers will validate claims where diagnosis code 042 Human Immunodeficiency Virus (HIV) Disease was billed as secondary.
This is currently the only DRG Validation issue that cannot be specifically tied to a single MSDRG. This issue involves any DRG where HIV appears as a secondary diagnosis.
Region B
CGI Federal added two new issues: one Automated Review and one that includes 3 DRG Validations:
Knee Orthoses — concerns certain additions not being separately payable.
Good luck, we know how hard it is to do. To find a complete, sortable listing of all their posted issues, visitthis 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.
When Will Medical Necessity Reviews Begin?
No one knows but the RACs, and so far, they ain’t sayin’.
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 list includes eight (8) MS-DRGs with very high Relative Weights (which equates to high dollar reimbursements and thereby potentially high RAC fees) and six (6) with claim volumes in the top 25% of all DRGs (providing a rather large number of claims to potentially audit).
Four (4) of the newly approved issues are for MSDRGs with Relative Weights of better than 10.0. Such claims have high dollar reimbursements, averaging over $45,000 per claim, nationwide.
Once again, these approval/postings seems to continue a pattern previously noted. (See our posts from February 9 and March 17.)
Virgina and West Virginia Now Included
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.
The New Issues
Below are the new posted and approved audit issues for RAC Region C, including Relative Weights and FY09 Discharge Ranks: (a low rank number relates to a large number of discharges for that DRG, nationwide)
MS-DRG 003: ECMO or Tracheotomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R. (RW 18.27; Rank 122)
MS-DRG 001: Heart Transplant or Implant of Heart Assist System with MCC (RW 24.85; Rank 720)
MS-DRG 005: Liver Transplant with MCC or Intestinal Transplant (RW 10.14; Rank 713)
MS-DRG 332: Rectal Resection with MCC (RW 4.78; Rank 297)
MS-DRG 562: Kidney Transplant (RW 1.38; Rank 79)
MS-DRG 011: Tracheotomy for Face, Mouth, and Neck Diagnoses with MCC (RW 4.73; Rank 476)
MS-DRG 012: Tracheotomy for Face, Mouth, and Neck Diagnoses with CC (RW 3.03; Rank 584)
MS-DRG 020: Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with MCC (RW 8.44; Rank 696)
MS-DRG 021: Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with CC (RW 6.21; Rank 696)
MS-DRG 927: Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours with Skin Graft (RW 13.74; Rank 629)
MS-DRG 929: Full Thickness Burn with Skin Graft or Inhalation Injury without CC/MCC (RW 2.01; Rank 728)
MS-DRG 023: Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis with MCC or Chemo Implant (RW 4.94; Rank 469)
MS-DRG 024: Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis without MCC (RW 3.26; Rank 212)
MS-DRG 007: Lung Transplant (RW 9.45; Rank 689)
MS-DRG 076: Viral Meningitis without CC/MCC (RW 0.83; Rank 510)
MS-DRG 461: Bilateral or Multiple Major Joint Procedures of Lower Extremity with MCC (RW 4.56; Rank 187)
MS-DRGs 799, 800, 801: Splenectomy w MCC, w CC, w/o CC/MCC (RW 5.11, 2.53, 1.59; Ranks 666, 709, 620)
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).
As faithful readers know, however, 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.
We will shortly post further analysis, in an overview of the DRG Validations posted to date by all four RACs.
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.
February 9, 2010 — Connolly Healthcare, the RAC for Region C (south & southeastern states), posted 19 new approved issues for review on their RAC Issues page, on Monday, February 8, 2010. Following the format they have been using to date, the listed issues include only single MS-DRGs, but are still not listed in any particular order.
All of the new issues are approved for DRG Validation, affecting all thirteen of the Region C states (AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX).
Top Ranked, High Dollar DRGs Added
Give their demonstrated proclivity to review high-dollar DRGs, these additions are not surprising, coming from Connolly.
See our recent analysis done for RAC Monitor,HERE.
We will shortly post another analysis of their approved issues list, analyzing the posted issues by DRG Relative Weights and by DRG Rank (in terms of the number of discharges, nationwide). Of the 52 DRGs with Relative Weights of better than 5.0, Connolly just added four (4) more to their list. Six(6) of the 19 new issues are ranked (by number of discharges) in the top 100 DRGs nationwide.
Three States Added to Previously Posted Issues
Notably, Arkansas, Lousiana and Mississippi were added to the states affected lists for all previously approved DRG Validation issues, now bringing them fully under the magnifying glass of the RAC. These three states were added to the posted DRG Validation issues on February 2.
Still No Medical Necessity Reviews
None of the posted issues are approved for review of Medical Necessity, and such reviews do not appear to have been approved for any of the RACs, to date. However, it is likely that the existing DRG Validation issues will all be approved for medical necessity review in short order, since the CMS RAC Review Phase-In Strategy allows for such approvals in calendar 2010.
More Useful Lists Available
Find links to all the RAC New Issues Pages here. For more useful lists, see below.
Use the links below to see details of the newly posted issues, in our database (Editor’s Note: this list appears here in the reverse order as posted by Connolly):
Includes 47 DRGs for Overpayment and 4 DRGs for Underpayment
CGI Federal, the RAC for Region B (western states), posted 20 new approved issues for review on their RAC Issues page, on Friday, January 22, 2010. Following the format being used by the Region D RAC, HDI, the listed issues are grouped together by Issue Name, which often includes multiple MS-DRGs.
All of the new issues are approved for DRG Validation, affecting all seven of the Region B states (IL, IN, KY, MI, MN, OH, WI). Notably, one of the new issues posted is approved for underpayment review, although only for four(4) of the five (5) MS-DRGs listed in the issue approved for overpayment review.
None of the new issues mention review of Medical Necessity, although such reviews do not appear to have been approved for any of the RACs, to date. However, it is likely that the existing DRG Validation issues will all be approved for medical necessity review in short order, since the CMS RAC Review Phase-In Strategy allows for such approvals in calendar 2010.
Find links to all the RAC New Issues Pages here. For more useful lists, see below.
Use the links below to see details, in our database:
The RAC contracted for the southern and southeastern states, Connolly Healthcare, continues to post new automated issues concerning dose-versus-units-billed, further proving that injections and infusions is a major target for RAC review, and a continuing concern for provider reimbursement, especially for physicians and outpatient settings.
In the continuing posting of issues, the RAC contracted for the upper midwestern states, CGI Federal, has now joined Connolly Healthcare in its posting of an issue that can possibly recoup all Medicare Part A charges for an inpatient claim, and still not even touch the dreaded issue of Medical Necessity.
recovery audit contractor
