Recent RAC Updates

DCS Healthcare (RAC for Region A) added a new issue for medical necessity claims to its CMS-approved issues list for providers in Maryland.

• APR-DRG 204-Syncope (All severity and risk of mortality levels). 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 APR-DRG 204-Syncope.

CGI (RAC for Region B) added three new issues to its CMS-approved list issues for providers in all Region B states.

• DRGs associated with All MDCs: MS-DRGs 984-986. MS-DRG Validation for DRGs Associated with All MDCs (Medical Necessity Excluded). MS-DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded on the hospital claim, matches both the attending physician description and the information contained in the medical record. Reviewers will validate MSDRGs 984, 985 and 986 for diagnoses and procedures potentially affecting or affecting the MS-DRG assignment. In addition, clinical validation of the codes billed may also be conducted.

• Rituximab – non-covered/non-allowed service-professional. An overpayment exists when a provider(s) bills for a service of J9310/Rituximab with an ICD-9 code that is not included in the list of covered ICD-9 codes for J9310/Rituximab with the applicable Local Coverage Determination document(s).

• Rituximab – non-covered/non-allowed service-outpatient. An overpayment exists when a provider(s) bills for a service of J9310/Rituximab with an ICD-9 code that is not included in the list of covered ICD-9 codes for J9310/Rituximab with the applicable Local Coverage Determination document(s).

If you need assistance in preparing for, or defending against RAC audits, or implementing a compliance program geared toward identifying and correcting potential risk areas related to RAC audits, please contact a Wachler & Associates attorney at 248-544-0888.