Medical Necessity Issues Approved for RACs

CMS has approved 18 medical necessity issues for the Recovery Audit Contractor (RAC) reviews in Region B (Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin). The issues were posted online by CGI, the Region B RAC, on August 12, 2010. The 18 approved issues for medical necessity review are:

• Chest pain MS-DRG 313 (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)
• Other vascular procedures w CC, w/o CC/MCC MS-DRG 253, 254 (Medical necessity review and MS-DRG validation)
• 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)
• 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)
• 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)
• 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)

For hospitals in Region B, the release of the issues serves as a final warning that there are only a few weeks before the RACs begin issuing their first potential denials on the above issues. For those hospitals not in Region B, approved medical necessity issues from other RACs should be released shortly and will likely be similar to the issues approved for Region B. As a result, all hospitals should begin a thorough review of their medical records to determine compliance with the above medical necessity issues.