Revenue Cycle

What could the RACs be thinking?

Recovery Auditor Report, February 4, 2010

With so many DRGs under review by all four RACs, it stands to reason providers are wondering exactly what specifics they should be focusing on within the organization.
 
So what should you be thinking about? Shannon McCall, RHIA, CCS, CCS-P, CPC-I, CCDS, director of coding and HIM at HCPro, Inc., offers her analysis of some issues that have been identified by HealthDataInsights (HDI). Though we don’t know exactly what RACs are looking for, McCall believes some of the likely MS-DRG targets may be:
  • DRG validation-burns—HDI is likely looking at the documentation and appropriate coding of mechanical vents since they can impact DRG assignment. The ICD-9-CM manual as well as American Hospital Association Coding Clinic has specific guidance of when a mechanical vent can be reported and how to calculate the time. 
  • DRG validation-endocrine, nutritional and metabolic disorders—The coding issues here would likely be validation of coding of CC/MCC conditions and possibly the appropriateness of coding diabetic related manifestations/complications which could impact DRG assignment in a positive of negative manner therefore they are looking for overpayments as well as underpayments.
  • DRG validation-eye procedures—The coding issues here would likely be validation of coding of CC/MCC conditions which could impact DRG assignment in a positive or negative manner therefore they are looking for overpayments as well as underpayments.
  • DRG validation-health status factors—Many of these diagnoses do not warrant admission as an inpatient. This would also be inclusive of some of the signs and symptoms DRGs.
  • DRG validation-septicemia—This seems to always be a big focus area for review because of specific coding guidance on sequencing.

Most Popular