Includes 29 MS-DRGs for Medical Necessity Review

Connolly Healthcare posted a new approved issue calling for DRG Validation review of 309 MS-DRGs and/or 141 ICD-9 diagnosis codes, on Thursday evening, March 17, 2011. Connolly is the CMS Recovery Audit Contractor for Region C, responsible for audits of healthcare providers who bill Medicare in 17 states and US territories.

The new issue is a first, in two ways: this single issue lists almost half of the 746 MS-DRGs that exist; and it is also the first issue posted by any RAC to call out a series of ICD-9 codes. The issue also marks yet another reversal in the format of their posts, once again calling out the MS-DRGs that are included for Medical Necessity Review, rather than those that are excluded.

Targeting ICD-9 Codes

The new issue calls out four complete series of codes, all part of the Injury and Poisoning Section of the ICD-9-CM Diagnosis Codes. The four series comprise all the diagnosis codes within one subsection, Complications of Surgical and Medical Care, Not Elsewhere Classified, which also happens to be the name given to the issue by Connolly.

The four ICD-9 code series, totaling 141 diagnosis codes, are:

• 996 Series – Complications peculiar to certain specified procedures (75 codes)
• 997 Series – Complications affecting specified body system not elsewhere classified (25 codes)
• 998 Series – Other complications of procedures not elsewhere classified (24 codes)
• 999 Series – Complications of medical care not elsewhere classified (17 codes)

Further analysis is forthcoming, but two things are obvious from a quick perusal of the codes involved.

First, the ICD-9 codes involved are very likely to encode to high-dollar DRGs. Claims with such codes could easily bill for over $10,000 each, up to more than $36,000 each.

Second, the DRGs involved are all over the map and do not easily cluster, although a quick analysis did show that one DRG did appear with the 996 series over 25% of the time: MS-DRG 314, Other Circulatory System Diagnoses with MCC. While 25% is not enough to be statistically conclusive, it does warrant for further analysis and a deeper investigation.

It is unclear, at this time, if there is any significant reason for those MSDRGs to be approved more than once for DRG Validation, and posted in multiple issues.