23 New Issues Approve Medical Necessity Review for 70 DRGs

Connolly Healthcare, the Recovery Audit Contractor (RAC) for 17 states posted 77 new issues on their Approved Issues webpage, late in the day on Friday, January 14, 2011. Once again, continuing the pattern that healthcare providers have come to expect from the 4 RACs and their respective webpages, the postings present confusing, incomplete and sometimes contradictory information.

According to their Statement of Work, the RACs are required by CMS to post their approved review issues on a public website before they can begin any widespread review of said issues. However, no format is stipulated in the Statement of Work for the website, nor for the pages listing the issues. The postings made Friday continue to offer no consistent format for these webpages, while adding some 17,000 words to the page, the largest single day’s changes made to any of the four RAC websites.

Of the 77 new issues posted, some list approval for a single MS-DRG, some list approval for multiple MS-DRGs, including anywhere from 2 to 32 in a single post. Of the 77 issues, we find:

• 54 issues concern DRG Validation only for specified MS-DRGs,
• 19 issues concern Medical Necessity only for specified MS-DRGs, and
• 4 issues cover both DRG Validation for specified MS-DRGs and Medical Necessity for some of the same MS-DRGs.

If we count the number of MS-DRGs involved, we find:

• 216 MS-DRGs newly approved for DRG Validation,
• 70 MS-DRGs newly approved for Medical Necessity Review.

Of the 70 approved for Medical Necessity Review, 46 are identified separately, while 24 are buried inside lists of MS-DRGs also approved for DRG Validation.

We say “buried” because the specific MS-DRGs approved for Medical Necessity Review are posted in a very confusing manner.

For example, here is the Issue Name (title) for a posting that includes both DRG Validation and Medical Necessity Review:

Hepatobiliary Disorders (At this time, Medical Necessity will be excluded from review for DRG(s) 434, 435, 436, 437, 438, 439, 440, 441, 443, 445)

The Description field for this issues includes, thankfully, a list of the MS-DRGs that the issue covers:

“Reviewers will validate principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS DRG 434, 435, 436, 437, 438, 439, 440, 441, 442, 443, 444, 445, 446.”

This method of listing the MS-DRGs requires the reader to compare the two long lists of MS-DRGs in the posting in order to figure out which MS-DRGs are approved for Medical Necessity Review. Doing so finally identifies just three (3) MS-DRGs — 442, 444, 446.

Listing issues like this is tantamount to walking into Denny’s and telling the waitress you want a “Slam” breakfast, but you don’t want the All-American Slam, the Belgian Waffle Slam, the Lumberjack Slam, or the French Toast Slam.

We have been told that the RACs are supposed to post new issues on their webpage exactly as they are approved, with the exact same language that is used in the many forms they are required to submit to CMS to garner approval for widespread review. Many providers are wondering (out loud, at least to this reporter) how it can be that Connolly can be making so many changes/edits or making such confusing posts if that is true.