by Sam Antonios, MD, FACP, FHM, CPE, CCDS
Over the last 18–24 months, health- care organizations have seen a surge in MS-DRG denials, sometimes referred to as clinical validation denials.
When reviewers from Medicare Advantage health plans, Recovery Auditors, or other private or contracted health plans analyze a clinical case submitted for reimbursement, they may determine that a particular disease should be removed from the claim. They argue that the clinical documentation in the medical record does not support the diagnosis submitted. In the vast majority of these cases, the removed diagnosis is a CC or MCC, which causes the MS-DRG to shift to a lower payment.
MS-DRG audits are nothing new, but their frequency has significantly increased over the last two years. In some circumstances, the volumes have been over- whelming. There have also been reports of cases where denials have been egregious, unjustified, or made with disregard for the treating physician’s opinion.
Although there is no surefire way to win an appeal, here are some tips to increase the likelihood of overturning MS-DRG denials.
One: If you believe the case has merit, file an appeal, even if the variance in dollar amount is insignificant. It may be tempting to let go of denials that minimally affect the reimbursement, but when the treating provider’s documentation is available, complete, and accurate, and the coding is correct per official coding guidelines, organizations should appeal. This maintains consistency and makes the appeals about data integrity, rather than payment.
Two: Write clearly and summarize first. The appeal reader will likely not want to spend a lot of time figuring out the intent of the appeal. The first few lines need to describe the clinical case and need for appeal succinctly. Additional details can be included in later paragraphs.
Also, remember to reference review articles, clinical guidelines, or other findings to support your appeal.
Three: Learn how to navigate the electronic health record (EHR) to find relevant information. The history and physical and the discharge summary may not capture the entire clinical picture.
Learn where to locate, and how to decipher, emergency department documentation, consultant reports, progress notes, nursing notes, and other provider documentation, which can often include vital information to a support an appeal.
Additionally, respiratory notes can reveal the status of the patient, including lung exams, respiratory effort, and need for respiratory treatments. The goal should be to offer a complete and accurate clinical picture of the patient.
Four: If possible, review records from transferring facilities to help describe the patient’s case. These records are likely scanned into the record later in the patient care process, but they should be collected before an appeal. Creatinine levels, electrolytes, and other laboratory findings can help differentiate acute and chronic symptoms and conditions.
Five: Keep track of denials electronically. Preferably, use denial-tracking software. If such software is not available, or too costly for your facility, spreadsheets can be just as effective. Remember to update and back up these records regularly.
Editor’s note: Antonios is the CDI and ICD-10 physician advisor at Via Christi Health in Wichita, Kansas. A board-certified internist, he manages the hospital EHR system, works closely with quality leaders to tackle challenging documentation requirements, and engages with physicians on CDI and quality initiatives. This article is an excerpt from its original which appeared in the Sept./Oct. edition of the CDI Journal. Contact him at Samer.Antonios@via-christi.org.
CMS finalized its proposal regarding the 2-midnight rule, essentially reverting to the physicians’ judgment for inpatient admissions provided that assessment is supported by medical record documentation and clinical findings. Questionable stays will be subject to review by the facility’s Quality Improvement Organization. CMS expects inpatient admissions for minor surgical procedures to be unlikely and will prioritize those cases for medical review. For hospital stays expected to last two midnights or longer, CMS policy remains unchanged. To read more from JustCoding, click here.
Other News Items:
Florida hospital overpaid $2.6 million, Medicare compliance review finds. Boca Raton Regional Hospital in Florida was overpaid $2.6 million over two years, according to a Medicare compliance review. The HHS Office of Inspector General audited a stratified random sample of 211 claims—206 inpatient and five outpatient—worth $1.86 million. The 400-bed hospital made errors on 50 inpatient claims, which caused a net overpayment of $514,449, OIG said. There were no mistakes on the outpatient claims. To read more from AISHealth, click here.
25 HIM benchmarking trends and insights. How are HIM professionals responding to challenges such as ICD-10, coder productivity, clinical documentation improvement, computer assisted coding, and outsourcing? ADVANCE for Health Information Professionals and Himagine Solutions, Inc. recently published a benchmark report, highlighting insights from more than 140 HIM professionals. News for CDI—70% of respondents have a formal CDI program in place at their facility and 25% of the staff reportedly hold dual credentials in both nursing and coding. To read more from HIT Consultant, click here.
1,800 hospitals increase payments under value-based purchasing. More than 1,800 hospitals will receive a boost in federal reimbursements next year under CMS’ value-based purchasing plan. The agency announced Nov. 9 that 600 more hospitals will earn increased payments in fiscal year 2016. Of the participating hospitals in the program, half will experience either a loss or gain of 0.4%. The top performers will receive a 3% boost in payments while the worst performers will be docked a maximum of 1.75%. To read more from FierceHealthFinance, click here.
Editor’s Note: “CDI Newsroom” is a regular feature highlighting CDI-related news from outside news organizations and websites.
Q: At what stage should an established program most likely experience a reimbursement plateau? One may naturally expect the physicians to improve as CDI programs hammer them with education. After we’ve gathered all the low-hanging fruits and go for the mangos? We ran the top principal diagnoses and also top diagnoses for our system. We are a home-grown program, about three years old now. Our team made $6 million last year. I know there are many query opportunities and ideas for program expansion but how do we find the right areas for our facility?
A: I am unaware of any industry standards that identifies a timeline of expectations for a plateau of reimbursement/physician documentation improvement. If you have a relatively stable medical staff with few changes, the program should mature and demonstrate physician documentation improvement more quickly than an organization that experiences high turnover of physicians, such as a university or teaching hospital. A teaching hospital may never plateau as the influx of residents and the constant rotation among specialties means educating physicians and capturing the “low hanging fruit” never ends. Each organization will have their own rate of turnover and educational needs for medical staff.
Such programs would have a lower query rate but maintain increased levels of CC/MCC and severity of illness/risk of mortality (SOI/ROM) capture. In other words, the physicians have retained and applied the education, they require less questioning but their documentation supports higher reimbursement levels.
The second variable in this equation is that as a CDI program matures the staff will find “different trees of low-hanging fruit” to pick. At the beginning, you learn to recognize potential documentation opportunities amongst the apples and oranges and begin to see a decrease in queries related to these but you learn there are opportunities in the lemon trees and the mangoes.
Lastly, organizations are constantly adding new services, new procedures and with each change CDI programs may identify entirely new opportunities. In other words, I have not seen in my experience a leveling off but more of an evolving focus as a program matures.
Self-education and participation in CDI networking are important in advancing your own career, your own knowledge, and your CDI program efforts. If you do not currently have tracking systems in place for individual CDI specialists’ and individual physicians’ query behaviors, you may want to. This might identify specific learning needs for individuals that could be targeted. For example, what diagnoses are the CDI specialists querying for? Does one CDI staff member miss sepsis opportunities or are there opportunities the entire team needs to learn about? If there a specific physician that needs intervention on a particular diagnoses?
Most successful CDI programs work closely with their coding teams. Expand on this collaboration by having the coding staff bring forward any trends or difficulties they’re seeing in daily practice. Ask to review any retroactive queries for trends and trouble spots. Identify any documentation improvement opportunities the CDI staff may have missed. The idea being, you and your CDI team won’t miss that opportunity next time.
If you do not have access to your organization’s Program for Evaluating Payment Patterns Electronic Report (PEPPER), seek out access. PEPPER is produced by CMS and it compares your organization to like organizations within your region. It identifies where you maybe an outlier for specific diagnoses and CC/MCC capture. You may be able to identify improvement opportunities in areas where you are a low outlier compared to your peers.
I often found my new fruit by reviewing the code set. Just opening up the code book and seeing what specificity was needed in code assignment for specific diagnoses often demonstrated for me areas of needed improvement. I would suggest doing that with theICD-10-CM code book. You can start asking questions related to ICD- 10 now so that the learning curve will not be so steep come October of next year.
Lastly, an exercise I suggest for new CDIs and one that might require repeating as the definitions do change is to take the list of CC/MCCs and highlight those diagnoses that are often seen within your population. You may find there is a “fruit basket” just sitting there that you never considered. If you identify codes that you have not thought to ask for look them up in the code books and learn what terms are needed to support their documentation. I promise you this effort will bring to light at least one diagnosis common to your population that you might not be capturing on a regular basis.
Wikipedia tells me there are over two thousand different fruits in the world so you have many to harvest!
When hospitals appeal their denials they typically win. The AHA’s RACTrac report indicates that hospitals appeal more than 40% of their denials with a roughly 75% success rate. That’s where CDI professionals come in.
CDI specialists know how to piece the various components of the medical record together, says Mary Smith (her name has been changed at her facility’s request) a Florida-based RAC denials coordinator. Smith joined her facility’s CDI team in 2007 during the program’s inception. She worked as the CDI coordinator for four years before making the leap to the RAC denials team. Smith, who also spent two years in the case management role, says she has “the perfect blend of professional backgrounds for this line of work. [She] can look at the record and see the different pieces of it and use that knowledge to
formulate an appeal.”
To get a head start on preparing for a possible full-time prepayment review process, ensure the completeness of medical records before they go out the door Make sure that the records do not have any signature issues, have been prereviewed, and contain all the necessary documentation. CDI specialists can also help with audit defense simply by being “aware of the targeted areas and [paying particular attention] when reviewing charts with those DRGs,” says Melanie Haycraft, RN, CCDS, RAC/government audit coordinator for North Oakes Health Systems in Hammond, La. “Consistent documentation with the appropriate criteria met is the only way to audit-proof the chart.”
by Amy Havard, RN
West Tennessee Healthcare is a public, not-for-profit healthcare system. Modern Healthcare magazine lists it as one of the top 10 largest, public, not-for-profit, healthcare systems in the country.
Jackson Madison County General Hospital (JMCGH), where we work, is considered the flagship of West Tennessee Healthcare. A 635-bed tertiary care center, it is the only tertiary care hospital between Memphis and Nashville, and serves a 17-county area of rural West Tennessee where approximately 400,000 people live. The CDI program at JMCGH was established in 2008 in an effort to face the challenges related to the impending changes in healthcare, especially the implementation of ICD-10.
We have a team of five experienced registered nurses who challenge themselves daily to come up with innovative ways to engage our medical staff. We believe our program is different from many because our primary focus is physician education, not the “number of charts reviewed.” We are also honored to have “hands on” support from the HIM/coding specialists, as well as our CDI department manager, director, and administration.
We are beginning to expand our focus to include educating our medical staff regarding the rising number of claims denials. These include Recovery Auditors (RAs), Medicare Administrative Contractors (MACs), TennCare (Medicaid), and other commercial cases.
Believe it or not, over the past five years our physicians have begun to ask us for information and look to us for education about what’s going on in the wide world of coding, documentation, reimbursement, and claims denials. We’ve found that they have no idea what a RA does or what a denial actually is. They had no concept that cases are being denied up to three years post discharge or that appeals could take up to two years more than that. They also had no idea that some regions are already recouping from physicians if their documentation/bill doesn’t correlate with the hospital charges/codes.
When the denials come in, I share some of the cases with the CDI nurses and then we use those examples in our educational sessions with the physicians. To see it in “real time” has had quite an impact on the medical staff. And once we started presenting them with dashboard graphs of the RA denial process (including the amount of money recouped by CMS from both our region and nationwide), the physicians (across most specialties) became almost frantic for our guidance. They’ve really started to call us, page us, email us….. You name it.
To help them really understand the situation in a meaningful way they want to see:
- Examples of denials and examples of how good documentation overturned or helped avoid a potential denial.
- How specificity and acuity of the illness/conditions could have been better captured in the documentation.
- How the lack of specificity in the record resulted in either the inability to appeal at all or caused the denial to be upheld.
- How the additional specificity of ICD-10 will affect not only their documentation but also denial management. We’ve really seen a spike in their willingness to begin putting ICD-10 specificity requirements into practice since we tied it back to the big picture regarding denial prevention. We are even started to query for some ICD-10 related diagnoses.
Ask yourself these questions when thinking about the future of your CDI program:
- What helps determine the case-mix index (CMI), average length of stay (ALOS), and severity of illness (SOI) and risk of mortality (ROM)?
- What can make the difference between a successful appeal and a denial being upheld?
- What can help you prevent denials, substantiate medical necessity and ensure core measures data is correct?
- What will help ensure you survive the implementation of ICD-10 in 2014?
The answer: Accurate and codeable clinical documentation!
If you’re not already actively using your hospital’s PEPPER (Program for Evaluating Payment Patterns Electronic Report), you’re missing out on a lot of valuable data. Data—including coded data—drives pay-for-performance, meaningful use, auditing targets, and more. Being ‘in the know’ about what your hospital’s data says in terms of the care provided is essential.
PEPPER provides Medicare claims data statistics for areas that the OIG, Quality Improvement Organizations, Medicare Administrative Contractors (MAC), and Recovery Auditors (RA) identify as being at risk for improper payments. It uses aggregated data to allow hospitals to see how they stack up against others in the state, jurisdiction, and nation.
The report, published by TMF Health Quality Institute, identifies potential over- and underpayments that hospitals can focus on internally. It also prioritizes specific target areas and provides guidance in terms of auditing and monitoring those targets.
Coding target areas include the following:
- Stroke and intracranial hemorrhage
- Respiratory infections
- Simple pneumonia
- Unrelated operating room procedures
- Medical DRGs with CC or MCC
- Surgical DRGs with CC or MCC
- Excisional debridement
- Ventilator support
- Single CC or MCC
PEPPER also targets the medical necessity of various conditions. In addition, it includes 30-day r-eadmissions to the same hospital or elsewhere and short stays (i.e., one- and two-day stays).
A hospital has an outlier if its percent in a particular target area is at or above the 80th percentile or is at or below the 20th percentile.
Various hospitals have shared information about how they’ve used PEPPER proactively. The PEPPER Web site provides testimonials about how hospitals are using the report.
If you haven’t already visited the PEPPER Web site, check out the following links:
- PEPPER User’s Guides for specific providers
- National-level data reports
- Medical necessity coding and audit tools to prevent improper payments
Auditors have been reviewing medical necessity for inpatient services for years and Recovery Auditors (RA) have recouped millions of dollars in overpayments. Now outpatient providers are beginning to see more and more medical necessity audits, especially in the ED and for evaluation and management (E/M) levels.
CMS continues to monitor E/M levels and indicated in the 2013 OPPS Final Rule that level distribution remains fairly normal and relatively stable distribution. CMS also notes a slight shift of Level 4 and 5 visits in relationship to Levels 1, 2, and 3.
“This is something we certainly want to keep our eye on and maybe take a second look at our criteria and the medical necessity for the services that we’re coding and billing,” says Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, AHIMA-Approved ICD-10-CM/PCS Trainer,president of Edelberg Compliance Associates of Baton Rouge, La. “When you see something in final rules or regulations or any of the transmittals that CMS is sending out, it tells you that CMS is going to be taking a closer look and that could mean audits for all of us.”
Overcoding in the ED is less of a problem than undercoding, Edelberg says.
CMS and RAs are increasingly scrutinizing short inpatient stays and observation services, says Joanne M. Becker, RHIT, CCS, CCSP, CPC, CPC-I, AHIMA approved ICD-10-CM/PCS Trainer. Becker is associate director in the Joint Office for Compliance at the University of Iowa hospitals and clinics in Iowa City.
Because of the increased scrutiny on one-day stays, many facilities are instead placing patients in observation, Becker says. The next logical step for RAs then is to focus on observation. “We even have heard that some RAs are looking at observation visits as to whether or not the patient should have even been there at all,” she says.
Editor’s Note: This article is an excerpt from JustCoding.com.
If your documentation isn’t ready for ICD-10, you’re not ready! Join ACDIS at 1 p.m. (Eastern) July 16 for the live, 90-minute audio conference, ICD-10: Auditing Existing Documentation. Experts Adelaide M. LaRosa, RN, BSN, CCDS, and Deborah Lantz, RHIA, explain how to review your current ICD-9 documentation in preparation for the ICD-10 transition, including steps to take now and during the next year to ensure successful ICD-10 implementation.
Following this 90-minute audio conference you will be able to:
- Examine existing methods of capturing documentation to identify problem areas
- Discuss how to audit existing documentation, paying attention to the top 25 diagnoses and procedures for your facility
- Describe an action plan to prepare ensure documentation is ready for ICD-10
- How are you capturing documentation?
- What are you currently doing to capture documentation for ICD-9?
- What should you be doing to prepare for ICD-10?
- Is senior leadership engaged?
- What will you do with the findings?
- Who will you present them to?
- Do you have a team in place?
- What actions will you take based on the results?
For more information or to order, call 800/650-6787 and mention Source Code EZINEAD or visit the HCPro Healthcare Marketplace.
Most healthcare providers have limited resources, including limited time to develop their own clinical documentation improvement (CDI) tools. The CDI Toolkit provides clinical information, practical information, and a variety of tools in CD-ROM format for easy adaptation or modification in numerous settings.
Complete and accurate documentation is necessary for appropriate financial reimbursement and has a long-lasting effect on physician and hospital quality scores. It is also necessary for public health reporting of disease and procedure outcome measures, including resource utilization. Clinical documentation specialists (CDS) are responsible for ensuring that documentation in the medical record includes complete and accurate, codable, terminology that facilitates accurate calculating and reporting of severity of illness (SOI) and risk of mortality (ROM). Inaccurate and nonspecific documentation leads to inappropriate reimbursement and profiling for providers and hospitals.
The Centers for Medicare & Medicaid Services (CMS) is assessing Medicare spending per beneficiary episode through its value-based purchasing (VBP) initiative. VBP aims to promote high- quality, safe, patient-focused care that avoids preventable adverse events, including healthcare-acquired conditions, while reducing costs.
SOI and ROM calculations based on the interaction of multiple comorbidities and sequencing of diagnoses are the underlying theme of quality reports. Conditions can affect SOI and ROM regardless of whether they are complications and comorbidities (CC) or major complications and comorbidities (MCC).
In this CDI Toolkit the clinical categories reflect the Major Diagnostic Categories, and within each section we have included specific examples of scenarios in which queries are necessary. A facility’s query process must consider etiology of the symptoms and/or disease and disease manifestations and/or consequences.
Increased clarity and specificity is important for accurate coding, but it’s also necessary for an accurate and complete reflection of patient acuity and provider performance.
Queries should seek clarification and specificity. They should not question providers’ clinical judgment. A query is not necessary if there is no clinical support of a diagnosis. Written and verbal queries that may be construed as leading providers are impermissible. Queries that appear to prompt a particular response are similarly impermissible.
Queries should present the facts in the current medical record. They should not introduce new information or information not in the current medical record. Query forms should not be designed so that only a signature is required. The same standards should apply regardless of whether a query is part of the permanent record. Additionally, diagnoses should be carried throughout a medical record and not appear only on a query.
Audits should be a part of any facility’s ongoing monitoring of its CDI program. Sample audit suggestions included in various chapters serve as an exploratory tool for non-punitive and process improvement opportunities.
Review your facility’s Short-Term, Acute-Care Program for Evaluating Payment Patterns Electronic Report (ST PEPPER) to determine whether an audit for medical necessity and/or coding is necessary. TMF Health Quality Institute develops and distributes ST PEPPER under contract with CMS. This report isn’t necessarily indicative of a problem; it provides benchmark data that compares a facility with other facilities.
If resources and time permit, consider a more formal random sampling. If resources and time are limited, consider a focused review of suspected problematic issues of concern nationwide, identified in your ST PEPPER report or through your denial management program. Consider monitoring one of your audit focuses during the first quarter (e.g., October–December), changing processes and implementing changes during the second quarter (January–March), and re-monitoring during the third quarter (April–June). Another audit could be monitored January–March, changes implemented April–June, and re-monitored July–September.
Consider self-audits during which clinical documentation staff compare their queries to the organization’s query policy and practice. CDI managers should conduct staff query audits for compliance monitoring. Managers also should audit cases with only one additional International Classification of Diseases code after the principal diagnosis code. Learning from others internally and externally through networking and national association membership is important.
Collaborate internally with the following colleagues:
- Providers (e.g., attending and consulting physicians, pathologists, radiologists, anesthesiologists, emergency department physicians, psychiatrists)
- Physician assistants and advanced practice nurses
- Non-providers (e.g., nurses, patient care technicians, dietitians, speech therapists, rehabilitative therapists, quality staff, laboratory, infection control, utilization, care management, risk management, dialysis, emergency department)
Collaborate with your medical records and forms committees and provide input regarding language included in any form that may directly or indirectly affect codable documentation. Expand your CDI steering committee to include multidisciplinary representation.
Externally collaborate with CDS’ locally, statewide, and nationally. Attend conferences, meet colleagues, and continue relationships post conference. Be open to new ideas and approaches. Be willing to share with others for the betterment of the profession.
Editor’s Note: This post is an excerpt from the introduction of The CDI Toolkit written by Nancy Rae Ignatowicz, RN, BS, MBA, CCDS. The CDI Toolkit contains sample queries, powerpoint presentations, educational materials, and other items to help CDI specialists advance their programs.
In the last month, CMS posted two separate sets of data that provide nationwide statistics on its Recovery Auditor program. The first update contains improper payment figures as well as the top Recovery Auditor issue per region. In the second update, CMS provides appeals statistics for fiscal year 2011.
Improper payment figures and top issues
Recovery Auditor activity saw a huge spike in the latest quarter, as statistics for overpayments and underpayments both saw significant increases. For the time period January 2012 through March 2012, CMS identified $588.4 million in overpayments and $61.5 million in underpayments for a total of $649.9 million in corrections. These numbers are up from $397.8 million and $24.9 million from last quarter, respectively. These numbers have climbed considerably since the start of the permanent program.
Since the beginning, CMS has identified $1.86 billion in overpayments and $245.2 million in underpayments for a sum of $2.1 billion in total corrections.
The correction amounts of each quarter of the program are as follows:
- October 2009–September 2010: $92.3 million
- October 2010–December 2010: $94.3 million
- January 2011–March 2011: $208.9 million
- March 2011–June 2011: $289.3 million
- July 2011–September 2011: $353.7 million
- October 2011–December 2011: $422.7 million
- January 2012 – March 2012: $649.9 million
Much like in the previous report, medical necessity issues remain the top target of each individual Recovery Auditor, three of which are cardiovascular procedures:
- Region A: Cardiovascular procedures (Medical necessity)
- Region B: Cardiovascular procedures (Medical necessity)
- Region C: Cardiovascular procedures (Medical necessity)
- Region D: Minor surgery and other treatments billed as inpatient stay (Medical necessity)
Also released by CMS in the past month is a report on appeals statistics for fiscal year 2011. The number of claims with overpayment determinations in 2011 was 903,372, but providers only appeal 56,620 of these claims. Of these appeals, 24,548 or 43.4% were reversed in the provider’s favor. Considering the relative success of providers in their appeal efforts, the fact that 846,752 claims did not get appealed comes as a bit of a surprise.
To further reinforce the decision to appeal an overturned case, consider the fact that of the 24,458 cases that were successfully appealed cases, that $37.9 million—or approximately $1,550 per case—was overturned in 2011. Overall, providers should consider the fact that there is a large amount of claim denials that should be appealed, accoridng to Deborah Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, LLC, in Shawnee, OK.
“I’m surprised at the low appeal rate given the volume of denials that I see that clearly warrant appeals,” says Deborah Hale. “This may be in part due to frustration with the process, an increased workload for hospitals associated with ICD-10 preparation and training, implementation of electronic health records, and the multitude of other high-priority projects—such as patient care—that hospitals are facing this year.”
Editor’s Note: This article originally published on the Revenue Cycle Institute website.