Indeterminate Descriptions Could Include Over 200 MS-DRGs

Connolly Healthcare, the Recovery Audit Contractor (RAC) for 17 states posted 35 new issues on their Approved Issues webpage and removed 4 older issues, mid-day on Wednesday, November 17, 2010. The postings continue the pattern that healthcare providers have come to expect from the 4 RACs and their respective webpages: confusing and incomplete. While the RACs are required by CMS to post their approved review issues on a public website, there is no format stipulated for the website, nor for the pages listing the issues. The postings made today are a prime example of how confusing and incomplete these listings can be.

Of the 35 new issues posted, 16 issues list approval for a single MS-DRG, 14 issues list approval for multiple MS-DRGs (anywhere from 2 to 18), and 5 issues list approval for an indeterminate number of MS-DRGs — that is, they list no MS-DRGs whatsoever, only calling out disorders, conditions or procedures in rather generalized terms. Those generalized terms lead us to deduce that the RAC intends to include broad ranges of MSDRGs under those issues. Unfortunately, those same 5 issues include approval for Medical Necessity review, and most probably include DRG Validation as well. (The description mentions that records will be reviewed to determine that the services paid for were not only medically necessary, but were both coded and billed correctly.)

Deletions vs. Edits

In the past, Connolly has edited previously posted issues, when Medical Necessity was approved for one or more of the MS-DRGs listed in an issue. Today, however, instead of editing a previous posting, the older posting was deleted from the list, and a “new” edited version was added, as if it were a “new” issue. This was done for four separate issues, for MS-DRGs 177, 178, 179 and 488. In each of these posts, the paranthetical phrase “(At this time, Medical Necessity excluded from review)” was removed from the posting. In the case of 177, 178 and 179, issues approving Medical Necessity review were in fact added to the list — assuming we have interpreted the postings correctly, here. For MS-DRG 488, however, there is not yet an issue listed that specifically states it has been approved for review of Medical Necessity.

We are submitting questions to both CMS and Connolly to get some clarification on the new postings, and will report here when we receive any answers.

DRG Validations

Below are the 30 new postings that specifically call out 94 MS-DRGs, approved for DRG Validation review. The titles below, however, have been edited to be more useful to providers:

Some of the above issues also include Medical Necessity approval for at least some of the MS-DRGs listed.

Duplicates exist in the list, as of 5pm today: MS-DRGs 417, 418 and 480 each appear twice.

Also, included in the list are duplicates of previously posted MS-DRGs: 031, 356, 357, 470 and 541 (as well as 177, 178, 179, already mentioned above).

Medical Necessity

Finally, here are the five new issues that do not list any specific MS-DRGs:

The descriptions of each of the above issues is virtually identical, and gives absolutely no indication of which MS-DRGs are included in these reviews. Perhaps the safest way to interpret these issues is to include the broadest number of possible MS-DRGs. In the case of Neurological Disorders, we might include the entire group of Diseases and Disorders of the Nervous System (75 MS-DRGs). For Respiratory Conditions: all Diseases and Disorders of the Respiratory System (40 MS-DRGs). For Cellulitus, while there are only two (2) Medical MS-DRGs specifically named so, there are six (6) other Surgical MS-DRGs that also refer to Cellulitus, and should therefore be considered as possible candidates. Finally, for Vagina, Cervix and Vulva Procedures, only two (2) MS-DRGs exist.

Total Over 200

Taken together, these five issues for Medical Necessity could include up to 142 MS-DRGs.

Adding those to the 94 counted in the other issues, the grand total could be as many as 236 MS-DRGs.