News: RACs add items to DRG validation review lists

Connolly Healthcare, CMS’ recovery audit contractor (RAC) for Region C, announced its first targets for complex review with a list of 24-DRGs in December 2009. A few weeks later it added 15 more DRGs to its list.

Connolly’s list was the first published, so it provided a good preview of what others could expect and CGI, the RAC for Region B, did not disappoint when it released its issues for non-medical necessity DRG-validation inpatient claims. HealthDataInsights (HDI), the RAC for Region D, and DCS Healthcare, the RAC for Region A, have continued to update their list of approved issues for auditing, as well.

Many of the concerns cited by the RACs are items clinical documentation improvement (CDI) specialists may already have well in hand; items like renal failure and septicemia.

CDI program directors should pull their own top 30 MS-DRG lists by frequency and compare it to their regional RAC lists, says Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS, director at Precyse Solutions.

While facilities with greater resources may be able to conduct reviews going back to October 1, 2007, (RACs are allowed to review records back to that date) CDI and HIM professionals should at a minimum implement “a second line of reviews to look for patterns in their DRGs,” Brown says. “The real point to take away from this list is that all the CCs and MCCs need to be documented consistently.”

Editor’s Note: For a complete listing of the latest CMS RAC approved items by state visit The Revenue Cycle Institute and click on Tools.

ACDIS members can download additional analysis in the January 2010 edition of the CDI Journal.