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RAC Begins Complex DRG Validation Audits

Andrea Kraynak, for HealthLeaders Media, December 7, 2009

Connolly Healthcare has announced the first issues approved for complex RAC review, so providers in several RAC Region C states could begin seeing medical record documentation requests at any time. Connolly is not yet reviewing for medical necessity.

The DRG-validation issues are approved for the following states: Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, and Texas.

According to the Connolly Web site, the 24 approved DRG validation issues are:

  • MS-DRG 163. Major chest procedures with major complication/comorbidity (MCC)

  • MS-DRG 164. Major chest procedures with complication/comorbidity (CC)

  • MS-DRG 165. Major chest procedures without CC/MCC

  • MS-DRG 166. Other respiratory system OR procedures with MCC

  • MS-DRG 167. Other respiratory system OR procedures with CC

  • MS-DRG 168. Other respiratory system OR procedures without CC/MCC

  • MS-DRG 207. Respiratory system diagnosis with ventilator support 96+ hours

  • MS-DRG 255. Upper limb and toe amputation for circulatory system disorders with MCC.

  • MS-DRG 329. Major small and large bowel procedures with MCC

  • MS-DRG 330. Major small and large bowel procedures with CC

  • MS-DRG 331. Major small and large bowel procedures without CC/MCC

  • MS-DRG 372. Major gastrointestinal disorders and peritoneal infections without CC/MCC

  • MS-DRG 386. Inflammatory bowel disease with CC

  • MS-DRG 394. Other digestive system diagnoses with CC

  • MS-DRG 432. Cirrhosis and alcoholic hepatitis with MCC

  • MS-DRG 813. Coagulation disorders

  • MS-DRG 871. Septicemia without mechanical ventilation 96+ hours with MCC

  • MS-DRG 872. Septicemia without mechanical ventilation 96+ hours without MCC

  • MS-DRG 981. Extensive OR procedure unrelated to principal diagnosis with MCC

  • MS-DRG 982. Extensive OR procedure unrelated to principal diagnosis with CC

  • MS-DRG 983. Extensive OR procedure unrelated to principal diagnosis without CC/MCC

  • MS-DRG 987. Nonextensive OR procedure unrelated to principal diagnosis with MCC

  • MS-DRG 988. Nonextensive OR procedure unrelated to principal diagnosis with CC

  • MS-DRG 989. Nonextensive OR procedure unrelated to principal diagnosis without CC/MCC

"I can certainly see why most of the DRGs Connolly is targeting are surgical DRGs," says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro.

A patient may undergo a procedure for a variety of different reasons, so providers would group an admission to a particular DRG based off the combination of the principal diagnosis, any present accompanying additional diagnosis (i.e., CCs or MCCs), and the principal procedure, McCall explains. Therefore, if the provider reports an incorrect code as the principal diagnosis, the assigned DRG may not be correct.

Similarly, principal procedures are by definition definitive in nature (as opposed to diagnostic or exploratory procedures), she says. So if two procedures meet the criteria, then the provider should select the one most closely related to the principal diagnosis, per the October 1990 AHA Coding Clinic.

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