RAC process heats up with complex validation audits

CMS Region C provider Connolly Healthcare has announced that it will begin complex RAC reviews for a new group of issues. This is the next step in the CMS clampdown, which ultimately will result in medical necessity reviews.

Connolly has been approved by CMS to do DRG validation in Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee and Texas.

Many of the validation issues CMS has approved have a surgical element, including:

* MS-DRG 163: Major chest procedures with major complication/comorbidity (MCC)

* MS-DRG 166. Other respiratory system OR procedures with MCC

* MS-DRG 207. Respiratory system diagnosis with ventilator support 96+ hours

* MS-DRG 255. Upper limb and toe amputation for circulatory system disorders with MCC.

Experts say that it's not surprising that CMS is focused on procedures that include accompanying diagnoses, considering that if the main diagnosis is incorrect, the other code probably won't be correct.

Get more background on the reviews:
- read the Connolly website