Resources to investigate RAC MS-DRG Validation and Medical Necessity Review

Are you struggling to research coding, payment, medical necessity and compliance rules related to the myriad reviews and issues from your Recovery Audit Contractor (RAC) or other investigators?  This article is designed to show you how to get to the most often-requested information as it relates to MS-DRG Validation and Medical Necessity Reviews.  Instructions apply to the Regulation & Reimbursement Suite or Audit & Revenue Resource Center unless otherwise noted.

• RAC Issues Tracker - On the left-hand navigation pane, click on RAC ISSUES link.  Here is a table of all issues being studied, sortable by RAC. Click to see issues for Region A and Region B in great detail, including mapping from the issue to related documentation and code pages.
• "Inpatient Only" List - This is part of the APC Codebook, or you can filter the Hospital OPPS Addendum B by Status Indicator "C".  The APC Codebook and download center is in the Codebooks link on the left-hand navigation pane.  To map from a HCPCS procedure code to the analogous inpatient ICD-9-CM Procedure code, navigate the tabular section of the ICD-9-CM Codebook or use code explorer and search by key word. To map from ICD-9-CM Procedure code to related MS-DRG, use the MS-DRG Grouper link on the Coding tab.  Stay tuned for future improvements in archived grouper versions and HCPCS-ICD crosswalk.
• AHA Coding Clinic for ICD-9-CM is available on the Audit and Revenue Resource Center in the left hand navigation pane. Click on the Coding Guidance link or go directly via the Coding Clinic ICD Link.
• IPPS Final Rules - Changes in grouping logic are discussed each year in the IPPS regulatory updates.  Go to the Inpatient Library for current and archived E-Books to understand DRG logic changes and rationale.
• CC/MCC Lists are published as part of the final IPPS rule each year.  Go to the INPATIENT library for archives. This year, we’ve made a comprehensive Valid ICD-9-CM Dx with CC/MCC flag file for FY 2011.  Check the ICD-9-CM 2011 Download Center.  Stay tuned for future improvements in easy-to-browse tables of CC/MCC Codes.
• Medical Necessity - Remember that medical necessity logic is also included in the CMS National Coverage determinations and the Benefit Policy Manual.  Both are available from the Coverage/LCD link on the left-hand navigation pane.  It is best practice to search these resources by key word, or browse, rather than code-searching.
• OIG Reports - On the left-hand navigation pane, click on the OIG Library link for full history of OIG reports that relate to RAC and other investigation issues.  It's a good idea to store searches for future updates.

While we have your attention, you may also be looking forward to ICD-10 implementation:

• ICD-9 to ICD-10 – we currently have the 2010 ICD-10-CM and ICD-10-PCS Codebook searchable along with the ICD-9-CM Codebook; go to the Codebooks or Coding Guidance link on the left hand navigation pane. We are working on a crosswalking tool as well; stay tuned for that.  We’ll be having a 90 minute free educational webinar about ICD-10 in September; watch daily alert for notice of that.