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

carla.engle@wolterskluwer.com

Winter Is Heating Up: Complex Reviews Are Here!

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