Posts 25 of the Same 29 MSDRGs Already on CGI, HDI, Connolly

DCS Healthcare posted approvals today for 225 DRG Validations, plus medical necessity review for 25 of the same 29 MSDRGs already approved earlier this month by the three other Recovery Audit Contractors (RACs). DCS, the RAC for CMS Region A, chose to post 23 of these approvals in nine (9) “new” issues, while two (2) MSDRGs previously approved for only DRG Validation were simply edited, adding notice of approval of medical necessity review/validation for only those two specific MSDRGs.

Adds 225 New DRG Validation Issues

The list below includes the nine (9) new postings with all the included MSDRGs:

Taken together, there are 225 new DRG Validations in the above list.

Medical Necessity Approved for Some DRGs

The list below shows all the MSDRGs now approved for Medical Necessity in Region A. While the list only includes 25 MSDRGs, all these are also included in the “List of 29,” the list of 29 MSDRGs originally approved for the other three RACs.

• MSDRGs 056, 057
• MSDRGs 190, 191, 192
• MSDRGs 249
• MSDRGs 253, 254, 292, 293, 302, 308, 312, 313, 314, 315, 316
• MSDRGs 391, 393
• MSDRGs 551, 552
• MSDRGs 640
• MSDRGs 683, 684
• MSDRGs 811

What’s Missing?

The four that did not make the cut for DCS are MSDRGs 069, 291, 682 and 689. Interestingly enough, three of those four are three of the highest weighted (and therefore highest paying) MSDRGs, the ones with an MCC. Also keep in mind, however, there are perhaps fewer of those claims available to review. DCS may be prefer volume to value, and therefore is more interested in reviewing more claims, even though they have a smaller contingency fee potential per claim.

Edits to Existing Posts

Two of the posts on the DCS site were edited to include limited medical necessity review. These previously approved DRG Validation issues, which both excluded medical necessity review, were edited to allow Medical Necessity for specific DRGs:

MSDRG 061, 062, 062, 064, 065, 066, 067, 068, 069: Intracranial Hemorrhage or Cerebral Infarction

Now allows medical necessity validation for MSDRG 069.

MSDRG 177, 189, 193, 291, 438, 441, 444, 592, 602, 682, 689, 691, 693: Severe Sepsis

Now allows medical necessity validation for MSDRGs 291, 682, and 689.

Still Nothing New?

No, the list is the basically same – a list we have begun to call “The List of 29”, the first 29 DRGs approved for Medical Necessity. Previously, we noted that providers should recognize that the list shows a proclivity to select whole DRG groupings, or all of the DRGs in a diagnosis grouping, which could include up to three MSDRGs.

Since the DCS list excludes a few of the highest paying of the MSDRGs, the list further reinforces the impression that the RACs and CMS are certainly aiming for volume, not only the highest paying DRGs.

Targeting More Facilities

As someone at one of the state hospital associations pointed out to us the other day, the inclusion of the lower paying DRGs moves the RAC aim off of the larger facilities, or at least expands the scope or size of the “net” they cast when reviewing records. The medium and smaller sized facilities bill fewer of the higher paying MSDRGs, than the larger facilities. The inclusion of the lower paying DRGs increases their exposure to RAC review.

Since this “25” mirrors the “29,” which probably includes the top ten DRGs at any facility, even the smaller ones, now all four of the RACs are set to enjoy what a fighter pilot would call a “target-rich environment.”