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18 Medical Necessity Issues OK'd for RAC Review

James Carroll, for HealthLeaders Media, August 16, 2010

CGI Technologies is the first Recovery Audit Contractor to post issues approved by CMS. All but one of them comes as no surprise, says one regulatory affairs expert.

Finally, the wait is over. The first set of approved medical necessity issues were posted August 12th by CGI Technologies and Solutions, the Region B Recovery Audit Contractor (RAC), following an AHA announcement last week that the initial review audits had been approved by the Centers for Medicare & Medicaid Services (CMS).

Medical necessity issues have been a hot topic for months. In a May CMS Open Door Forum call, a CMS representative suggested that medical necessity issues had been submitted to CMS, but CMS had not yet approved them —yet anticipated doing so in the "near future." However, the delay comes as no surprise, according to Michael Taylor, MD, senior medical director of government and regulatory affairs at Executive Health Resources in Newtown Square, PA.

"This is very consistent with the pattern we've seen with RACs since the roll out of the permanent program," he says. "CMS has been very deliberate in vetting the subjects that RACs are allowed to review."

Eighteen issues for medical necessity review were posted to the CGI website, and all but one of them comes as no surprise, according to Taylor.

  • Syncope and collapse MS-DRG 312 (Medical necessity review and MS-DRG validation)
  • Red blood cell disorders with MCC MS-DRG 811 (Medical necessity review and MS-DRG validation)
  • Other vascular procedures w CC, w/o CC/MCC MS-DRG 253, 254 (Medical necessity review and MS-DRG validation)
  • Other circulatory system diagnoses with MCC MS-DRG 314, 315, 316 (Medical necessity review and MS-DRG validation)
  • Chest pain MS-DRG 313 (Medical necessity review and MS-DRG validation)
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