In a prior article regarding RAC Prepayment reviews, I mentioned that this demonstration project, which began in September 2012, targeted several states whose claims historically resulted in high rates of improper payments. These were seven states with high populations of fraud and error-prone provider claims (FL, CA, MI, TX, NY, LA, IL) and four states with high claims volumes of short inpatient hospital stays (PA, OH, NC, MO). The purpose of this demonstration was to lower the improper payments before they occur and prevent the pay and chase model that exists now. This will allow the RAC to review the claims before they are paid. The Centers for Medicare & Medicaid Services (CMS) adds to the Prepay Edits posted on its website for January 2014.

Prepayment Review Demonstration

January 15, 2014 – The following tables contain the most recent prepayment review updates:

Table 1 Prepay Edits

Period of Review



September 2012

MS-DRG 312

Syncope & Collapse

January 2013

MS-DRG 069

Transient Ischemia

March 2013

MS-DRG 377-379

G.I. Hemorrhage

May 2013

MS-DRG 637-639


June 2013

MS-DRG 252-254

Other Vascular Procedures

July 2013

MS-DRG 391-392

Esophagitis, Gastroenteritis, and Misc. Digestive Disorders

August 2013

MS-DRG 673-675

Other Kidney & Urinary Tract Procedures

Table 2 Prepay Edits

Month Began


January 2014


Blepharoplasty  – (Inpatient Hospitals, Professional Services & Outpatient Hospitals)

Skilled Nursing Facility and Coding Validation – (Skilled Nursing Facilities)

Trastuzumab (Herceptin), Multi-dose Vial Waste – (Outpatient Hospitals, Professional Services)

Home Health – Medical Necessity & Conditions to Qualify for Services – (Home Health Agencies)

J9310 Rituximab Dose vs. Units Billed – (Outpatient Hospital)

Skilled Nurse Length of Stay – (Home Health Agencies)


RAC Issues for the Week of January 27 – January 31, 2014:

No approved issues were posted to the RAC contractor websites.

About the Author

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payers.

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