HDI, which has a territory encompassing 17 states in the western U.S., is now cleared for medical necessity review of the same DRGs recently approved by CMS for CGI Federal, the RAC for Region B. Medical necessity reviews are now available to RACs in 24 states.


It is now even more likely that half of the top 20 DRGs in any facility are either now or will soon be targets of RAC reviews for medical necessity. Again, those DRGs were already likely targets for DRG validation, as well as reviews of physician admission orders and coding of principal and secondary diagnoses.


Same DRGs, Different Posts


The 29 DRGs already approved for Region B are listed differently on the HDI website, compared to the CGI website. And, while tracking changes on these two sites are already difficult (due to the way they are constructed), they sites also use totally different methods to post their approved issues.


Compare these two “titles” for the same issue:


MSDRG 056, 057, 069: Nervous System Disorders – from CGI;


DRG Validation-Nervous System Disorders – from HDI.


Neither title tells the user that there has been a change to the posted issue.


Not even the dates of the files show any change, despite that fact that they have been modified.


29 DRGs in 10 Issues


Below is a list of the 29 DRGs embedded in the 10 original postings from the HDI website:



Original Posted



Issue Title

Date Posted

056 057 069

DRG Validation-Nervous System Disorders


191 192 193

DRG Validation-MDC 04 Respiratory



DRG Validation-Cardiac Procedures


253 254 291 292 293 302 308 313 314 315 316

DRG Validation-Cardiovascular Diseases



DRG Validation-Cardiovascular, Other


391 393

DRG Validation-Gastrointestinal Disorders


551 552

DRG Validation-Musculoskeletal Disorders



DRG Validation-Endocrine, Nutr’l & Metab Disorders


682 683 684 689

DRG Validation-Kidney & Urinary Tract Disorders



DRG Validation-Blood & Immunological Disorders


None Posted as “New”


It would seem that “new” does not mean the RAC is able to use a “new” review approach, adding medical necessity to its mix. Instead of posting “new” issues for Medical Necessity, two of the RACs have now shown they will simply rewrite the descriptions of their “old” issues when posting Medical Necessity.


In my previous article, “Top DRGs Approved for RAC Medical Necessity Review: But What’s New?” this tactic was described as “not expected,” since no one I know predicted this would happen – we all expected Medical Necessity to be listed as “new” issues. Now, however, we are expecting this, which only confirms how difficult it is to stay informed of the issues the RACs are reviewing.


Again, I wind up concluding… so, what’s new about that?


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 site devoted to providing knowledge, resources and compliance aids for U.S. healthcare professionals who are involved in revenue cycle management.


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