CMS Releases July 2012 Issue of Medicare Quarterly Provider Compliance Newsletter

on Friday, 20 July 2012. All News Items | Recovery Auditor | MAC Reviews

This quarterly educational product is aimed at helping Providers “understand the major findings identified by Medicare Administrative Contractors (MACs), Recovery Auditors, Program Safeguard Contractors, Zone Program Integrity Contractors, the Comprehensive Error Rate Testing (CERT) review contractor and other governmental organizations, such as the Office of Inspector General.”

So, what contractors have also targeted the DRGs included in the July Newsletter in your part of the country?

Below you will find a spreadsheet that lists the specific DRGs reviewed in the current Newsletter. This spreadsheet will enable you to:

  • Quickly identify what instigated the DRG Specific Review,
  • What type of review was performed (DRG Validation or Medical Necessity),
  • Has your MAC targeted this DRG for a Pre-Payment Review; and
  • Has your Recovery Auditor targeted this DRG for a Post-Payment Review?
July 2012 Medicare Quarterly Provider Compliance Newsletter Specific DRGs Reviewed
DRG DRG Description What instigated the review? Type of Review? Medicare Administrative Contractor Recovery Auditor
Pre-Payment Target Post-Payment Target
Cahaba, GBA Palmetto Novitas Solutions, Inc. DCS: Region A Connolly: Region C
DRG Validation Med Nec. DRG Validation Med Nec.
296 Cardiac arrest, unexplained w/MCC "CMS pre-approved certain MS-DRGs for medical necessity reviews including DRG 296" and "MS-DRG 640" Medical Necessity No No No Yes Yes Yes No
640 Nutritional & Misc. Metabolic Disorders w/MCC No No No Yes Yes Yes Yes
68 Nonspecific CVA & Precerebral Occlusion w/o infarct w/o MCC CMS identified these DRGs "for medical record review based on the risk of improper payment for inpatient care when outpatient care was provided." Medical Necessity No No No Yes Yes Yes Yes
69 Transient Ischemia Yes No No Yes Yes No Yes
70 Nonspecific cerebrovascular disorders w/MCC No No No No Yes Yes Yes
71 Nonspecific cerebrovascular disorders w/CC No No No No Yes Yes Yes
72 Nonspecific cerebrovascular disorders w/o CC/MCC No No No No Yes Yes Yes
73 Cranial & peripheral nerve disorders w/MCC No No No No Yes No Yes
74 Cranial & peripheral nerve disorders w/o MCC No No No No Yes Yes Yes
103 Headaches w/o MCC No No No No Yes Yes Yes
312 Syncope & collapse Yes No No Yes Yes Yes Yes
308 Cardiac arrhythmia & conduction d/o w/MCC Prior improper payments have been found by: CMS Top Volume DRGs, OIG and PEPPER reports Target area data for 2 day stays for cardiac arrhythmias DRG Validation No No No Yes Yes Yes Yes
309 Cardiac arrhythmia & conduction d/o w/CC No No No Yes Yes Yes Yes
264 Other Circulatory System O.R. Procedures Reviewers validated principal diagnosis, secondary diagnoses and procedures affecting or potentially affecting the DRG. DRG Validation No No No Yes Yes Yes Yes
542 Pathological fractures & musculoskeletal & conn tiss, malig w/MCC "The DRGs related to pathological fractures have been identified by Program for Evaluation Payment Patterns Electronic Reports (PEPPER) data as having potential for error." DRG Validation No No No Yes Yes Yes Yes
543 Pathological fractures & musculoskeletal & conn tiss, malig w/CC No No No Yes Yes Yes Yes
544 Pathological fractures & musculoskeletal & conn tiss, malig w/o CC/MCC No No No Yes Yes Yes Yes
391 Esophagitis, Gastroenteritis & Misc. Digestive D/O w/MCC The OIG, RAC Demonstration Project and Medicare CERT (2007 & 2008) found errors in assigning GI Tract Disorder related DRGs. A specific example with DRG was provided in the Compliance Newsletter. DRG Validation No No No Yes Yes Yes Yes
393 Other Digestive System Diagnosis w/MCC "This review was completed by a licensed clinician, such as a nurse, therapist or physician." Medical Necessity No No No Yes Yes Yes Yes

Sources: Medicare Quarterly Provider Compliance Newsletter Volume 2, Issue 4 - July 2012 / Medicare Administrative Contractor(MAC) and Recovery Auditor websites.

MMP, Inc. encourages our clients to review the complete Newsletter as it provides examples of review findings, guidance on how to avoid the problems identified and resources supporting the review findings.

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