Likely RAC Targets Revealed

 

Risk areas should be addressed with coding audits, coding education, clinical documentation improvement programs, utilization review and case management guidelines, medical necessity guidelines and physician education.

 

Inpatient

• Respiratory Dxes w/Ventilator (old DRG 76) (incorrect code)
– MSDRG 166 – Other Respiratory System OR Procedures w/MCC
– MSDRG 167 – Other Respiratory System OR Procedures w/CC
– MSDRG 168 – Other Respiratory System OR Procedures w/o CC/MCC

• Respiratory Infections & Inflammations, Age > 17 w/CC (old DRG 79) ¹(incorrect code)
– MSDRG 177 Respiratory Infections & Inflammations w/MCC
– MSDRG 178 Respiratory Infections & Inflammations w/CC
– MSDRG 179 Respiratory Infections & Inflammations w/o CC/MCC

 

• Respiratory System diagnosis with Ventilator Support (old DRG 565/566) ¹(incorrect code)
– MSDRG 207 Respiratory System diagnosis w ventilator support 96+ hours
– MSDRG 208 Respiratory system diagnosis w ventilator support <96 hours

• Other Circulatory System OR Procedures (old DRG 120) ¹ (incorrect code)
– MSDRG 264 Other circulatory system OR Procedures

• MS DRGs 286/287 – Circulatory Disorders except AMI w/Caridac Cath w MCC/woMCC2
– Treated in wrong setting (medically unnecessary)

 

• MS DRGs 291/292/293 Heart Failure/Shock w MCC/w CC/wo CC/MCC2
– Treated in wrong setting (medically unnecessary)
– Coding errors

 

• MS DRGs 308/309/310 Cardiac arrhythmia & Conduction disorders wMCC/w CC/wo CC/MCC (incorrect code)

 

• Chest pain (Old DRG 143) ¹(medical necessity)
– MSDRG 313 Chest Pain

 

• Excisional Debridement (incorrect code)¹,²
– Wound Debridement & Skin graft except hand, for musculoskeletal and connective tissue disorders (old DRG 217)

• MSDRG 463 Wound debridement & skin graft except hand for musculoskeletal connective tissue disease w MCC
• MSDRG 464 Wound debridement & skin graft except hand for musculoskeletal connective tissue disease w CC
• Wound debridement & skin graft except hand for musculoskeletal connective tissue disease w/o CC/MCC

 

– Medical Back Problems (old DRG 243) (medical necessity)

• MSDRG 551 Medical Back Problems w/MCC
• MSDRG 552 Medical Back Problems w/oMCC

 

– Skin Graft and/or Debridement for Skin Ulcer or Cellulitis w/CC(old DRG 263)¹,² (correct coding)

• MSDRG 573 Skin graft &/or debridement for skin ulcer or cellulitis w/MCC
• MSDRG 574 Skin graft &/or debridement for skin ulcer or cellulitis w/CC
• MSDRG 575 Skin graft &/or debridement for skin ulcer or cellulitis w/o CC/MCC
  

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• MS DRGs 640/641 Nutritional & Metabolic disorders wMCC/woMCC (correct coding)

 

• Septicemia (old DRG 576)¹,² (coding)
– MSDRG 870 Septicemia w MV 96+ hours
– MSDRG 871 Septicemia w/o MV 96+ hours w/MCC
– MSDRG 872 Septicemia w/o MV 96+ hours w/o MCC

 

• Extensive OR Procedure unrelated to principal diagnosis (old DRG 468) ¹(coding)
– MSDRG 981Extensive OR procedure unrelated to principal diagnosis w/MCC
– MSDRG 982 Extensive OR procedure unrelated to principal diagnosis w/CC
– MSDRG 983 Extensive OR procedure unrelated to principal diagnosis w/oCC/MCC
– MSDRG 853 Infectious & parasitic diseases w OR procedure w/MCC
– MSDRG 854 Infectious & parasitic diseases w OR procedure w/CC
– MSDRG 855 Infectious & parasitic diseases w OR procedure woCC/MCC

 

• Other Cases with high MS-DRG weight with low charges or LOS (coding)

 

• MCC/CC triplet rate (high % of claims assigned to MS-DRGs with MCC or CC in comparison with other facilities) (coding)

Discharge Status Codes²

 

Patients went to sub acute care and billed with “01”

 

Outpatient²

 

• Neulasta (medically unnecessary)
• Speech Language Pathology (medically unnecessary)
• Therapy units billed(medically unnecessary)
• Infusion Services (medically unnecessary)

– Multiple Colonoscopies (45355, 45378, 45380, 45383, 45384, 45385) (medically unnecessary)
– Multiple procedures on the same day (medically unnecessary)

• E.g. CPT code 47562 (Cholecystectomy) 3 units billed

• Outpatient charges without Medical Necessity diagnoses (LCD or NCD)

• Inpatient Medical Necessity Targets
– Short Stays with weak principal diagnoses

• Abdominal Pain
• Asthma
• Dehydration
• Diabetes

– 1 day stays
– 3-day stays with discharge status of discharge to SNF
– Readmissions within 72 hours of discharge
– IRF following joint replacement surgery
– Cardiac defibrillator implant in wrong setting
– 7 day readmit to same or other acute facility (early discharge?)

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There are other targets to consider as well. The Office of Inspector General (OIG) and other CMS agencies have a list of targeted DRGs which the RAC may use as a basis for a complex review. These targets are:

 

Old DRG	Description	MS-DRG
014	Intracranial Hemorrhage & Stroke with Infarction	064, 065, 066
015	Nonspecific Cerebrovascular and precerebral occlusion without infarction	067, 068
524	Transient Ischemia	069
079	Respiratory infections & inflammations >17 w/CC	177, 178
080	Respiratory infections & inflammations w/oCC	179
089	Simple Pneumonia & Pleurisy >17 w/CC	193
087	Pulmonary edema & Respiratory failure	189
088	COPD	190, 191, 192
127	Heart Failure & Shock	291, 292, 293
088	COPD	190, 191, 192
096	Bronchitis & Asthma >17 w/CC	202
089	Simple Pneumonia & Pleurisy >17 w/CC	193
096	Bronchitis & Asthma >17 w/CC	202
121	Circulatory Disorders w/AMI & Major Complications, Discharged Alive	280
124	Circulatory Disorders except AMI w/Cardiac cath and complex diagnosis	286
122	Circulatory Disorders w/AMI wo major complications, discharged alive	281, 282
125	Circulatory Disorders except AMI w/Cardiac cath wo complex diagnosis	287
127	Heart Failure & Shock	291, 292, 293
140	Angina Pectoris	311
130	Peripheral Vascular Disorders w/CC	299, 300
128	Deep Vein Thrombophlebitis	294, 295
132	Atherosclerosis w/CC	302
140	Angina Pectoris	311
138	Cardiac arrhythmia & conduction disorders w/CC	308, 309
140	Angina Pectoris	311
140	Angina Pectoris	311
143	Chest Pain	313
174	GI Hemorrhage w/CC	377, 378
182	Esophagitis, Gastroenteritis, & Misc, Digestive Disorders >17 w/CC	391
188	Other Digestive System Diagnosis >17w/CC	393, 394
180	GI Obstruction w/CC	389
239	Pathological Fracture & Musculoskeletal & Connective Tissue Malignancy	542
243	Medical Back Problems	551, 552
296	Nutritional & Misc. Metabolic Disorders >17 w/CC	640
182	Esophagitis, Gastroenteritis & Misc. digestive disorders >17 w/CC	391
316	Renal failure	682,683
331	Other Kidney & Urinary tract diagnoses >17 w/CC	698, 699
320	Kidney & UTI >17 w/CC	689
296	Nutritional & Misc. metabolic disorders >17 w/CC	640
416	Septicemia >17	871, 872
320	Kidney & UTI >17 w/CC	689
430	Psychoses	885
425	Acute Adjustment Reactions & disturbances of psychosocial dysfunction	880
565, 566	Respiratory system diagnosis with ventilator support	207, 208
121	Circulatory disorders w/AMI & major complications, discharged alive	280, 281, 282
565, 566	Respiratory system diagnosis with ventilator support	207, 208
127	Heart Failure & Shock	291, 292, 293

 

In the coming months, I will present in depth discussions of these targets and the pertinent coding and medical necessity issues involved.

 

____________________

¹ VHA Presentation 2008

² The Medicare Recovery Audit Contractor (RAC)Program: Update to the Evaluation of the 3-year Demonstration June 2008

 

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About the Author

 

Cheryl Servais has more than 25 years of experience in Health Information Management. In her position at Precyse Solutions, Ms. Servais’ responsibilities include planning, designing, implementing and maintaining corporate-wide compliance programs, policies and procedures, and updating them to accommodate changes in federal and other regulations. In addition, she oversees training and development programs related to ethics, compliance and patient privacy; develops and chairs compliance and privacy advisory committees at the Executive and Board levels; and takes an active role in professional organizations.

 

Cheryl E. Servais, MPH, RHIA, is Vice President, Compliance and Privacy Officer for Precyse Solutions

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