Medical Necessity Descriptions Differ


Not all the descriptions for medical necessity review are the same, even within a single RAC’s approved issues list. Be sure to read the descriptions in RAC postings carefully. Do not assume that all the medical necessity reviews concern short-stay or uncomplicated admissions. Some issues do indicate that this is what the RAC is looking for, but not all of them. Remember, when a RAC applies to CMS for approval of widespread review of an issue, they have to be fairly specific. However, that doesn’t mean that what was described is all they will be looking for – and that’s assuming we can even count on a posting being accurate, which of course we all know from experience is no guarantee. If one has the ability to look for just one-day stays, then by all means, do so, but don’t stop there.


DRG Validation and DRG Reassignment


Also, don’t forget to pay close attention to those DRG triplets (such as 291, 292, 293 for heart failure) RACs are posting – if they are approved for all three MS-DRGs in a triplet, providers should look carefully at how their coders are choosing principle and secondary diagnoses, making sure that the documentation is there to fully support the DRG assignment as filed.


When a RAC is looking at three closely related MS-DRGs, it is perhaps a signal that the assignment itself is suspect and the RACs have enough evidence to show a common problem, which could explain how they got the issue approved for all of them. The same attention should be paid to the few DRG doublets that exist (the ones for which there is no DRG for the CC level of severity, so there are only two DRGs in the set).


Some Statistics


Here are some statistics about where the RACs stand when it comes to their approved issues lists – that is, who has what and who has how many DRGs posted as approved issues.


Of the 746 MS-DRGs, we have:

  • 367 approved for review by all four RACs (so more than half now are being reviewed),
  • 240 approved for three RACs,
  • 103 approved for two RACs,
  • 27 approved for only one RAC, and finally,
  • Nine are not approved by any RAC.

If we look at the top 100 MS-DRGs ranked by discharge volume:

  • All 100 are approved for Region D,
  • 94 are approved for Region A,
  • 82 are approved for Region C, and
  • 79 are approved for Region B.

Next week, I plan to offer further analysis of what these figures say about what the RACs are pursuing.


The Slam Board


Finally, here is what I’m calling the RAC Roundup Slam Board: I intend to report on this weekly, counting the number of approved issues, the number of DRGs approved for DRG validations and the number of DRGs approved for medical necessity review.


Overall number of Approved Issues:


1)   Region C leads with 385,

2)   Region A has 155,

3)   Region B has 130, and

4)   Region D has 106.


Overall number of DRGs approved for DRG Validation:


1)   Region D leads with 731 (missing just 15 to complete the set),

2)   Region A has 679,

3)   Region C has 518, and

4)   Region B has 483.

Overall number of DRGs approved for medical necessity review:


1)   Region C leads with 145,

2)   Region A has 133  (recently doubled in number, as mentioned above),

3)   Region B has 124, and

4)   Region D has an even 100.


About the Author


Ernie de los Santos is the chief information officer for eduTrax®. He joined the company at its inception and has been responsible for the creation, development and maintenance of the eduTrax® portals – a set of Web sites devoted to providing knowledge, resources and compliance aids for U.S. healthcare professionals who are involved in revenue cycle management.


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