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All Four RAC Regions Have Recently Added Additional Issues Approved for Review in RAC Audits

DCS Healthcare: The Region A RAC added three new medical necessity claims to its approved issues list. These claims are:

  • Peripheral/cranial nerve and other nervous system procedures with MCC (MS-DRG 040);
  • ECMO or tracheostomy with MV 96+ hrs or PDX except face, mouth and neck with major O.R. (MS-DRG 003);
  • Skin graft and/or for skin olcer or cellulitis without CC/MCC

Providers located in Pennsylvania, Washington D.C., New Jersey, Delaware, New York, Connecticut, Vermont, Maine, Massachusetts, New Hampshire, Rhode Island are affected by these new approved issues.

CGI: RAC Region B has added three new medical necessity issues, four new DRG validation issues and four issues involving durable medical equipment (DME). The new approved issues include:

  • Medical necessity issues:
    • Acute inpatient hospitalization – surgical cardiovascular procedures MS-DRG: 246-254, and 263 – 265;
    • Acute inpatient hospitalization – diseases and disorders of the digestive system MS-DRGs 347 through 358 and 368 through 395;
    • Acute inpatient hospitalization – conditions of the circulatory systems MS-DRG: 286-293, 299-305, and 308-316.
  • DRG validation issues:
    • Burns: MS-DRGs 927-929 and 933-935 MDC 22;
    • Dental and oral diseases: MS-DRGs 157-159.
  • DME issues:
    • DME home glucose testing supplies;
    • DME water circulating heat pad with pump.

RAC Region B includes providers in Indiana, Michigan, Minnesota, Illinois, Kentucky, Ohio and Wisconsin.

Connolly Healthcare: Thirty new issues have been added to the approved issues list for RAC Region C providers. Examples of the new approved issues include:

  • DRG validation issues:
    • Hypertensive encephalopathies MS-DRGs 078 and 079;
    • Cranial and peripheral nerve disorders MS-DRG 074;
    • Radiotherapy.
  • DME issues:
    • Infusion supplies (A4221) – excessive units;
    • Ankle foot orthotic (AFO) and knee ankle foot orthotic (KAFO) custom fabricated versus prefabricated codes.

These new issues are applicable to providers in RAC Region C, which includes Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, North Carolina, New Mexico, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia, Puerto Rico and the U.S. Virgin Islands.

HealthDataInsights: The Region D RAC has posted nineteen new issues for medical necessity reviews. These claims include:

  • Acute inpatient hospitalization – nutritional and miscellaneous metabolic disorders without MCC (DRG 641);
  • Acute inpatient hospitalization – minor skin disorders without MCC (DRG 607);
  • Acute inpatient hospitalization – poisoning and toxic effects of drugs without MCC (DRG 918);
  • Nutritional and miscellaneous metabolic disorders with MCC (DRG 640).

HealthDateInsights is the Region D RAC contractor which includes providers located in Alaska, Arizona, California, Hawaii, Iowa, Idaho, Kansas, Missouri, Montana, North Dakota, Nebraska, Nevada, Oregon, South Dakota, Utah, Washington, Wyoming, Guam American Samoa and Northern Marianas.

If you have any questions about the application of these approved new issues or any questions regarding RAC or Medicare audits, please contact a Wachler & Associates attorney at 248-544-0888.