It's finally begun: CMS's Recovery Audit Contractors (RACs) have started reviewing claims for medical necessity, though at this point only inpatient claims are being targeted. Remember: There are four permanent RACs that have jurisdiction over various regions of the country. Only one of them, CGI Technologies and Solutions, Inc., is targeting medical necessity (also known as "complex" reviews). CGI is the RAC for Region B, which covers Michigan, Minnesota, Illinois, Indiana, Kentucky, Ohio and Wisconsin. Inpatient claims in these seven states will be subject to medical necessity reviews, which will begin with CGI asking you for detailed records.
CGI is targeting six issues for medical necessity review and diagnosis-related group (DRG) validation:
- Syncope & collapse MS-DRG 312
- Red blood cell disorders w MCC MS-DRG 811
- Atherosclerosis w MCC MS-DRG 302
- Chest pain MS-DRG 313
- Other circulatory system diagnoses w MCC MS-DRG 314, 315, 316
- Other vascular procedures w CC, w/o CC/MCC MS-DRG 253, 254