Facilities in Alabama, Georgia, Tennessee, Texas, North Carolina and South Carolina were reporting receipts of complex RAC review letters, although they were not related to medical necessity. At this time all such issues remain excluded from any of these reviews, but stay tuned in 2010 for more on that.
Connolly also posted a number of new issues in December; there are 59 total DRG validation issues now listed on their issues Web site.
Approved DRG Validation Issues
The following table is a list of the current DRG validation issues posted to the Connolly Web site (http://www.connollyhealthcare.com/RAC/pages/approved_issues.aspx) as of Jan.3.
|
MS-DRG |
Issue Name |
States Affected |
|
163 |
Major Chest Procedures with MCC: MS-DRG 163. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
164 |
Major Chest Procedures with CC: MS-DRG 164. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
165 |
Major Chest Procedures without CC/MCC: MS-DRG 165. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
166 |
Other Respiratory System O.R. Procedures with MCC: MS-DRG 166. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
167 |
Other Respiratory System O.R. Procedures with CC: MS-DRG 167. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
168 |
Other Respiratory System O.R. Procedures without CC/MCC: MS-DRG 168. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
207 |
Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
252 |
Other Vascular Procedures with MCC: MS-DRG 252 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
255 |
Upper Limb and Toe Amputation for Circulatory System Disorders with MCC: MS-DRG 255. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
256 |
Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
260 |
Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
262 |
Cardiac Pacemaker Revision Except Device Replacement without CC/MCC: MS-DRG 262 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
264 |
Other Circulatory System O.R. Procedures: MS-DRG 264 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
329 |
Major Small and Large Bowel Procedures with MCC: MS- DRG 329. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
330 |
Major Small and Large Bowel Procedures with CC: MS-DRG 330. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
331 |
Major Small and Large Bowel Procedures without CC/MCC: MS-DRG 331. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
335 |
Peritoneal Adhesiolysis with MCC: MS-DRG 335 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
356 |
Other Digestive System O.R. Procedures with MCC: MS-DRG 356 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
357 |
Other Digestive System O.R. Procedures with CC: MS-DRG 357 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
372 |
Major Gastrointestinal Disorders and Peritoneal Infections with CC: MS-DRG 372. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
386 |
Inflammatory Bowel Disease with CC: MS-DRG 386. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
394 |
Other Digestive System Diagnoses with CC: MS-DRG 394. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
423 |
Other Hepatobiliary or Pancreas O.R. Procedures with MCC: MS-DRG 423 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
432 |
Cirrhosis and Alcoholic Hepatitis with MCC: MS- DRG 432. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
463 |
Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with MCC: MS-DRG 463 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
464 |
Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with CC: MS-DRG 464 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
465 |
Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders without CC/MCC: MS-DRG 465 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
573 |
Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with MCC: MS-DRG 573 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
574 |
Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC: MS-DRG 574 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
575 |
Skin Graft and/or Debridement for Skin Ulcer or Cellulitis without CC/MCC: MS-DRG 575 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
576 |
Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with MCC: MS-DRG 576 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
578 |
Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis without CC/MCC: MS-DRG 578 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
622 |
Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with MCC: MS-DRG 622 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
623 |
Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with CC: MS-DRG 623 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
624 |
Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC: MS-DRG 624 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
673 |
Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
674 |
Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
813 |
Coagulation Disorders: MS-DRG 813. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
853 |
Infectious and Parasitic Diseases with O.R. Procedure with MCC: MS-DRG 853 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
854 |
Infectious and Parasitic Diseases with O.R. Procedure with CC: MS-DRG 854 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
855 |
Infectious and Parasitic Diseases with O.R. Procedure without CC/MCC: MS-DRG 855 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
856 |
Postoperative or Posttraumatic Infections with O.R. Procedure with MCC: MS-DRG 856 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
857 |
Postoperative or Posttraumatic Infections with O.R. Procedure with CC: MS-DRG 857 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
858 |
Postoperative or Posttraumatic Infections with O.R. Procedure without CC/MCC: MS-DRG 858 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
871 |
Septicemia without Mechanical Ventilation 96+ Hours with MCC: MS-DRG 871. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
872 |
Septicemia without Mechanical Ventilation 96+ Hours without MCC: MS-DRG 872. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
876 |
O.R. Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
901 |
Wound Debridements for Injuries with MCC: MS-DRG 901 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
902 |
Wound Debridements for Injuries with CC: MS-DRG 902 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
928 |
Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
935 |
Nonextensive Burns: MS-DRG 935 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
939 |
O.R. Procedure with Diagnoses of Other Contact with Health Services with MCC: MS-DRG 939 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
940 |
O.R. Procedure with Diagnoses of Other Contact with Health Services with CC: MS-DRG 940 |
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
981 |
Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
982 |
Extensive O.R. Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
983 |
Extensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
987 |
Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
988 |
Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with CC – MS-DRG 988. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
|
989 |
Nonextensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC – MS-DRG 989. |
Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas |
The Request
Each claim in the Connolly request lists a rationale. Here is an example of one from a request letter:
DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary’s medical record. Reviewers will validate for MS-DRG XXX, previously DRG XXX, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Good Cause Language: The RAC Demonstration Project (3/2005 thru 3/2008) found an overwhelming majority of errors in assignment for DRG XXX, currently MS-DRG XXX, resulting in overpayments to hospitals. The RAC identified errors in the data that could be traced to the hospitals’ medical record practice. An analysis of your billing data indicates that a potential aberrant billing practice may exist for this DRG.
The request from Connolly itself is pretty straightforward, encapsulating all of the necessary elements to identify the correct claim:
1) Request No.
2) Claim/Ref No.
3) Medical Record No.
4) Begin DOS
5) End DOS
6) Member DOB
7) Member
8) Patient Control No.
9) Member Last Name
Figure 1: An excerpt from a RAC complex request letter for the DRG validation rationale:
Required Documentation
In the request letter, Connolly provides a list of all the required documentation to return to it within 45 days:
1) Face sheet
2) Discharge summary
3) History and physical
4) Emergency Room records
5) All nursing notes
6) ER nursing notes
7) Consultations
8) Physician orders
9) Therapy treatment plan and notes
10) Physician progress notes
11) Laboratory reports
12) Radiology reports
13) Operative reports
14) Pathology reports
15) ICD-9-CM codes submitted
16) Physician query
17) UB 04 or HCFA (CMS) 1500
18) Medication administration records
Figure 2: An excerpt from a RAC complex request letter on the support documentation requested
Some Pointers
- Include a copy of each original request letter along with a copy of the attached pull list/spreadsheet affixed to the additional documentation when you return requested records to the auditor. This is to ensure that all the documentation is connected to the correct claim.
- Keep a copy to ensure that, if the auditor has questions after it receives the documentation, you have copies of your own.
- Even if you haven’t received requests yet – if Connolly is not your auditor, or you are not located in one of the states listed for a specific issue – stay on top of the published issues from all of the auditors and include them in your own preemptive-defense audit strategy. As time goes on, other auditors more than likely will have the same issues posted to their Web sites.
About the Author
Carla Engle, MBA, is a product manger for MediRegs, a Wolters Kluwer company. Her background includes more than 20 years in hospital and physician practice operations, particularly in reimbursement and billing functions. Prior to joining Wolters Kluwer recently, she was the vice president of compliance for a national revenue cycle solutions company and prior to that was in the Reimbursement Training Department with HCA. For several years she headed up the Part A Fraud Investigation Unit for a CMS Program Safeguard Contractor (PSC) where she was successful in the prosecution of several national cases. In her revenue cycle compliance capacity, she worked with a number of clients in California and Florida with Recovery Audit Contractors (RACs) in setting up processes and appeals.
Contact the Author