Connolly Healthcare has posted a new approved issue calling for DRG Validation review of 309 MS-DRGs and/or 141 ICD-9 diagnosis codes.
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 postings were made Thursday evening.
The new issue is a first in two ways: this single issue lists nearly half of the 746 MS-DRGs that exist; and 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 the Connolly posts in that it calls 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 the following:
- 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)
A Quick Analysis
We looked at inpatient claims from 2009 for a single hospital's files that included at least one of the ICD-9 codes from the four series posted by Connolly. The query returned 254 claims for that one year (Keep in mind that the RAC can look back 36 months, so they would likely find a large number of claims with these codes.)
Upon careful examination two things appeared very obvious:
First, the claims were all high value - the relative weights for the DRGs in those claims averaged between 2.0 to 2.5. This made the dollar value of such claims roughly $10,000 to $12,000. Many were over $20,000. The total dollar volume of just the claims from the 996 Series (164 claims) was $3.46 million.
Second, looking only at the claims with the 996 Series codes, the DRGs were widely distributed, but there was a single DRG that appeared about 25 percent of the time (in 43 of 164 claims): DRG 314, Other Circulatory System Diagnoses with MCC. While it's not enough to be a statistically significant finding, at least there is one DRG on which we can focus for further analysis and a deeper investigation to see if a problem might exist in this facility.
So the question becomes, "Is it worth the cost to investigate?"
A Risk Worthy of Attention
Is $3.46 million enough on which to think this is perhaps worth spending some time and resources in order to avoid future problems? Perhaps there is no problem in your facility, but even for a large facility the risk identified should be high enough to warrant expending resources. Can your facility afford to ignore a risk that large? And this is just part of a single issue.
Meanwhile, perhaps we can at least be grateful that Connolly waited until after business hours to post this new issue, so as not to spoil anyone's St. Patrick's Day celebration - except mine.
Ernie de los Santos is the Founder of the California-based blog network, The RAC Shadow, where he maintains a free database of all RAC Approved Issues. This post orginally appeared at RACMonitor.com.