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18 Medical Necessity Issues OK'd for RAC Review

James Carroll, for HealthLeaders Media, August 16, 2010

 

 

  • Atherosclerosis with MCC MS-DRG 302 (Medical necessity review and MS-DRG validation)
  • Heart failure and shock with MCC, with CC and w/o CC/MCC DRG 127 MS-DRG 291, 292, 293 (Medical necessity review and MS-DRG validation)
  • Esophagitis, gastroenteritis and miscellaneous digestive disorders w/MCC DRG 182 MS-DRG 391 (Medical necessity review and MS-DRG validation)
  • Musculoskeletal disorders 539-541, 545-558, 564-566 (Medical necessity excluded except for MS-DRG 551 and 552)

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  • Chronic obstructive pulmonary disease DRG 88 MS-DRG 190, 191 (Medical necessity review and MS-DRG validation)
  • Respiratory 175, 176, 180-188, 192, 196-206 (Medical necessity excluded except for MS-DRG 192
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  • Nutritional and metabolic disorders DRG 296 MS-DRG 640 (Medical necessity review and MS-DRG validation)
  • Kidney and urinary tract infections w/MCC DRG 320 MS-DRG 689 (Medical necessity review and MS-DRG validation)
  • GI disorders 368-370, 374-376, 380-390, and 392-395 (Medical Necessity Excluded except for MS-DRG 393)
  • Percutaneous cardiovascular procedures MS-DRG 247, 249, 251 (Medical necessity excluded except for MS-DRG 249)
  • Renal failure DRG 316 MS-DRG 682, 683, 684 (Medical necessity review and MS-DRG validation
  • Nervous system disorders MS-DRG 052-063, 067-074, 077-086, 088-093, 097-099, 101, 102 (Medical necessity excluded except for MS-DRG 056, 057 and 069)
  • Cardiac arrhythmia and conduction disorders with MCC or w/CC DRG 138, MS-DRG 308, 309 (Medical necessity excluded except for MS-DRG 308)

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    "In looking at percutaneous cardiovascular procedures, it says that medical necessity is excluded except for DRG 249. This came as a bit of a surprise because during the last year, the MACs have been heavily auditing DRG 247, which is a drug eluting stent, instead of 249, which is non-drug eluting, and a less common target of contractor attention," says Taylor. "It will be interesting to see if the RACs and MACs maintain this slightly different focus; if their areas of review are being purposefully kept apart; or if this is just a temporary situation before the rest of these stents become an approved medical necessity issue for the RACs."

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