The following issues were recently approved by Medicare's recovery audit contractors program.
RAC Region A: Diversified Collection Services
Musculoskeletal fractures (At this time, medical necessity is excluded from the review.)
Posted: Oct. 27, 2010.
States affected: Conn., D.C., Del., Mass., Maine, N.H., N.J., N.Y., Pa., R.I. and Vt.
Description: MS-DRG Validation for MS-DRGs 533, 534, 537, 538, 562 and 563 MS-DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded on the hospital claim, matches both the attending physician description and the information contained in the medical record. Reviewers will validate MS-DRGs 533, 534, 537, 538, 562 and 563 for diagnoses and procedures affecting the MS-DRG assignment.
Nervous system procedures (At this time, medical necessity is excluded from the review.)
Posted: Oct. 7, 2010
States affected: Conn., D.C., Del., Mass., Maine, N.H., N.J., N.Y., Pa., R.I. and Vt.
Description: MS-DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded on the hospital claim, matches both the attending physician description and the information contained in the medical record. Reviewers will validate the principal and secondary diagnoses and procedures affecting or potentially affecting assignment of MS DRGs 020, 021, 022, 023, 024, 028, 029, 030, 031, 032, 033, 037, 038, 039, 040, 041 and 042.
Cataract removal — Excess units
Posted: Oct. 7, 2010.
States affected: Mass., Md., Maine, N.H., N.Y., Pa., R.I. and Vt.
Cataract removal can only occur once per eye for the same date of service. This issue identifies overpayments associated to outpatient hospital providers billing more than on unit of cataract removal for the same eye.
RAC Region B: CGI Federal
No recent postings
RAC Region C: Connolly Healthcare
Seizures MS-DRG 100 & 101 (At this time, Medical Necessity is excluded from review).
Date of Service: Oct. 1, 2010.
States affected: Ala., Ark., Colo., Fla., Ga., La., Miss., N.M., N.C., Okla., P.R., S.C., Tenn., Texas, V.I., Va. and W.Va.
Description: 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 principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
RAC Region D: HealthDataInsights
No recent postings
RAC Region A: Diversified Collection Services
Musculoskeletal fractures (At this time, medical necessity is excluded from the review.)
Posted: Oct. 27, 2010.
States affected: Conn., D.C., Del., Mass., Maine, N.H., N.J., N.Y., Pa., R.I. and Vt.
Description: MS-DRG Validation for MS-DRGs 533, 534, 537, 538, 562 and 563 MS-DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded on the hospital claim, matches both the attending physician description and the information contained in the medical record. Reviewers will validate MS-DRGs 533, 534, 537, 538, 562 and 563 for diagnoses and procedures affecting the MS-DRG assignment.
Nervous system procedures (At this time, medical necessity is excluded from the review.)
Posted: Oct. 7, 2010
States affected: Conn., D.C., Del., Mass., Maine, N.H., N.J., N.Y., Pa., R.I. and Vt.
Description: MS-DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded on the hospital claim, matches both the attending physician description and the information contained in the medical record. Reviewers will validate the principal and secondary diagnoses and procedures affecting or potentially affecting assignment of MS DRGs 020, 021, 022, 023, 024, 028, 029, 030, 031, 032, 033, 037, 038, 039, 040, 041 and 042.
Cataract removal — Excess units
Posted: Oct. 7, 2010.
States affected: Mass., Md., Maine, N.H., N.Y., Pa., R.I. and Vt.
Cataract removal can only occur once per eye for the same date of service. This issue identifies overpayments associated to outpatient hospital providers billing more than on unit of cataract removal for the same eye.
RAC Region B: CGI Federal
No recent postings
RAC Region C: Connolly Healthcare
Seizures MS-DRG 100 & 101 (At this time, Medical Necessity is excluded from review).
Date of Service: Oct. 1, 2010.
States affected: Ala., Ark., Colo., Fla., Ga., La., Miss., N.M., N.C., Okla., P.R., S.C., Tenn., Texas, V.I., Va. and W.Va.
Description: 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 principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
RAC Region D: HealthDataInsights
No recent postings