Connolly Posts Medical Necessity Issues

on Monday, 30 August 2010. All News Items

Connolly has posted Medical Necessity Issues on their website.  This comes a little over two weeks after the American Hospital Association (AHA) announced that the Centers for Medicare & Medicaid Services’ New Issue Review Board had approved the first “medical necessity review” audits.

Connolly posted all 18 types of inpatient hospital claims that have been approved for medical necessity review audits.  They indicated that “RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions.”  They further noted that “Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly.  Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly.”

The approved Medical Necessity Issues include:

  • Degenerative Nervous System Disorders with and without MCC
  • Transient Ischemia (TIA)
  • Chronic Obstructive Pulmonary Disease with MCC / with CC / without CC/MCC
  • Percutaneous Cardiovascular Procedure with Non Drug-Eluting Stent without MCC
  • Other Vascular Procedures with CC / without CC/MCC
  • Heart Failure & Shock with MCC / with CC / without CC/MCC 
  • Atherosclerosis with MCC
  • Cardiac Arrhythmia & Conduction Disorders with MCC
  • Syncope & Collapse
  • Chest Pain
  • Other Circulatory System Diagnoses with MCC / with CC / without CC/MCC
  • Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders with MCC
  • Other Digestive System Diagnoses with MCC
  • Medical Back Problems with MCC / without MCC
  • Nutritional & Miscellaneous Metabolic Disorders with MCC
  • Renal Failure with MCC / with CC / without CC/MCC
  • Kidney & Urinary Tract Infections with MCC
  • Red Blood Cell Disorders with MCC

Tucked into the new medical necessity audits Connolly has also indicated that some of the Medical Necessity issues may also be reviewed for DRG Validation.  The specific instruction by Connolly is that “RACs WILL ALSO REVIEW documentation for DRG Validation requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospitals on its claim, matches both the attending physician description and the information contained in the beneficiary’s medical record.  Reviewers will validate for MS-DRG, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.”

A complete list of approved Validation and Medical Necessity Issues can be viewed at

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