Medical Necessity Reviews Approved for Some New DRGs

DCS Healthcare, the Recovery Audit Contractor (RAC) for CMS Region A, posted approvals on Tuesday morning, December 7, for 21 new CMS approved issues for RAC review, including 110 new DRG Validations, plus medical necessity review for Renal and Urinary Tract Disorders, which would include at least 19 MSDRGs, some not previously approved for such review by any of the other RACs.

New Issues Include 110 New DRGs

The list below includes the 21 new postings with all the included MSDRGs:

In total, there are 110 new MSDRGs approved for DRG Validation in the above list.

Medical Necessity Approved for Other DRGs

One of the new issues posted reflects approval for Medical Necessity Review (MNR) of any Medicare claims submitted for Renal and Urinary Tract Disorders. This likely includes all MSDRGs included in the Medical DRGs in MDC 11, Diseases and Disorders of the Kidney and Urinary Tract: 19 total MSDRGs, 682 thru 700.

Unlike postings by other RACs, it is not clear from the language on their website if these Medical Necessity Reviews will include DRG Validation or coding/billing review. However, some might argue that it is unlikely that a review of medical necessity would not include a review of the medical coding, as submitted.

Problems Noted in the DCS Postings

One of the postings, the one for Amputations, actually has the wrong MSDRGs listed, calling out 286 and 287, which were elsewhere correctly listed for Circulatory Disorders. (In our list, above, we have correctly identified the MSDRGs for Amputations.)

Also, another posting, for Pancreas, Liver and Shunt Procedures, mentions neither exclusion or inclusion of medical necessity review. It is the only DRG Validation posting by DCS that does not mention MNR, one way or the other.