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Recent RAC Activity

DCS Healthcare, RAC for Region A, recently added 40 new issues to its CMS-approved issues list for providers in Pennsylvania, Delaware, Connecticut, New Jersey, New York, New Hampshire, Massachusetts, Maine, Vermont and D.C. A sampling of the newly approved issues is included below. Please visit DCS Healthcare’s website to view the remaining issues.

  • Medical Necessity Review (MNR) for MS-DRG 922 Other Injury, Poisoning and Toxic Effect Diagnosis with MCC. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of MS-DRG 922 Other Injury, Poisoning and Toxic Effect Diagnosis with MCC.
  • Medical Necessity Review (MNR) for MS-DRG 464 Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with CC. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of MS-DRG 464 Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with CC.
  • Medical Necessity Review (MNR) for MS-DRG 617 Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders with CC Disorders with CC. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of MS-DRG 617 Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders with CC.
  • Medical Necessity Review (MNR) for MS-DRG 215 Other Heart Assist System Implant. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of MS-DRG 215 Other Heart Assist System Implant.
  • Medical Necessity Review (MNR) for MS-DRG 734 Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy with CC-MCC. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of MS-DRG 734 Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy with CC-MCC.
  • Medical Necessity Review (MNR) for MS-DRG 836 Acute Leukemia without Major O.R. Procedure with CC. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of MS-DRG 836 Acute Leukemia without Major O.R. Procedure with CC.
  • Medical Necessity Review (MNR) for MS-DRG 340 Appendectomy with Complicated Principal Diagnosis without CC-MCC. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of MS-DRG 340 Appendectomy with Complicated Principal Diagnosis without CC-MCC.

Connolly Healthcare, the RAC for Region C, recently added two new issues to its CMS-approved issues list.

  • Incorrect payments for Maintenance and Servicing of capped rental DME. Payment for maintenance and servicing of capped rental DME equipment is included in the rental payments, and should not be reimbursed separately.
  • Incorrect modifiers billed with bilateral indicator 2 – OP. Certain modifiers cannot be billed with Bilateral Surgery Indicator 2 because the Relative Value Units (RVUs) are already based on the procedure being performed as a bilateral procedure.

If you need assistance defending against RAC audits or implementing a compliance program that will help identify and correct potential risk areas related to RAC audits, please contact a Wachler & Associates attorney at 248-544-0888.