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As part of the Pre-payment Demonstration Project for Medicare, the July 2013 target for RAC contractors will be MS-DRGs 391-392, which addresses Digestive Disorders such as esophagitis and gastroenteritis as well as other miscellaneous digestive disorders. RAC contractors should be posting these review issues to their websites soon. 

As mentioned in my previous pre-payment article (Drill Down: Pre-Payment Reviews and Short Stays),pre-payment reviews are complex review types and will require the provider to submit documentation before a payment or denial is made. The RAC will be looking for documentation for DRG validation, requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, match both the attending physician description and the information in the beneficiary’s medical record. Auditors will review claims for principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the focused MS-DRGs.

Pre-payment Audit Workflow

  • ADRs will come from the FI/MAC
  • Providers will have 30 days to send documentation
  • Recovery Auditors will review and communicate payment determination to FI/MAC

–      Providers will receive determination within 45 days
–      RAC will also send detailed review results letter

  • Providers may appeal the denial

–      Same appeal rights as other denials








Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/RecoveryAuditPrepaymentReview.html

RAC issues for the week of July 29 – August 2, 2013:

No issues were posted by RAC contractors.

About the Author

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payors.

Contact the Author


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