by Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS
One of the many coder/CDI obligations is to report noncompliant activities. Your employer’s compliance plan may direct you to report these noncompliant observations to the compliance officer or a compliance hotline.
When you report your observations, you may do so anonymously or by identifying yourself. It is your decision which approach you take, but regardless, you still have the obligation to report.
Commonly reported coding-relating issues are:
- Documenting services long after the service was provided and possibly never provided
- Routinely reporting high-level evaluation and management or MS-DRG codes (upcoding) when the documentation does not support the high level
- Failure to code to the highest level of specificity when the documentation is present
- Queries that encourage or lead a physician to add documentation which would increase the level of reimbursement for a particular case
- Adding charges to a claim for services provided
- Providing services that are not medically necessary
When a coder/CDI specialist observes actions inconsistent with quality healthcare, the more detail provided to the compliance officer will help in the investigation. Depending on investigation findings, major, minor, or no changes may result. Sometimes, actions observed may appear inappropriate, but upon investigation, the actions were consistent with clinical practice.
For example, a coder/CDI specialist may consider the actions of another staff member to be too zealous in optimizing the codes to achieve higher reimbursement. The term optimization is defined as a procedure used to make a system or design as effective or functional as possible.
When coders “optimize” the coding process, they attempt to make coding for reimbursement as accurate as possible. This process may involve querying the physician for clarification of conditions or augmenting conditions documented. If done in a nonleading way, the organization will obtain the highest entitled reimbursement.
When the investigation illustrates the need to make changes, you will probably see activities such as reeducation, updating of policies, and possibly the removal of staff members.
Unfortunately, there are times when an individual reports legitimate compliance concerns and does not see actions being taken to correct the concern. In these situations, a person may wish to “blow the whistle” and contact an agency outside of the organization to file a lawsuit. This type of lawsuit is known as a qui tam lawsuit.
Qui tam lawsuits are a type of civil lawsuit whistleblowers bring under the False Claims Act, a law that rewards whistleblowers if their qui tam cases recover funds for the government. Qui tam is an abbreviation of the Latin phrase meaning “who as well for the king as for himself sues in this matter.”
Qui tam cases are different from other types of lawsuits, such as those involving personal injuries, because the person bringing the lawsuit is not the one who has been harmed.
A recent example of qui tam is the South Florida case where physician Mario Baez, a partner in a physician practice, turned whistleblower on his partner when he determined that his partner was submitting fraudulent claims. Nearly all the patients seen at IM Medical and Lake Worth Medical were diagnosed with a serious but rare spinal disorder called ankylosing spondylitis, when only 1 in 1,000 people truly have this disorder, according to Baez. The disorder increased the risk score for the physicians who were participating in a Medicare Advantage health plan reimbursement arrangement with Humana. The higher the risk score, the greater the reimbursement. The interesting twist on this qui tam is that Baez was not just whistleblowing on his partner but also on Humana. Humana should have been able to detect this fraudulent activity.
Taking a qui tam action requires much consideration, because often the whistleblower is identified during the legal proceedings. Having legal counsel guidance will be beneficial. If the case is lost, the situation can be embarrassing.
However, if the case is won, there may be financial rewards for the whistleblower depending on how much the whistleblower’s details of the situation contributed to the success of the suit. Regardless, following your convictions to surface inappropriate care should result in better care for patients thereafter, and that is the right thing to do.
Editor’s note: Dunn is a past president of the American Health Information Management Association and recipient of its 1997 Distinguished Member and 2008 Legacy awards. In 2011, she served as the interim CEO of AHIMA and received a Distinguished Service Award from its board of directors. Dunn is the chief operating officer of First Class Solutions, Inc., a health information management consulting firm based in St. Louis. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. For questions please contact editor Amanda Tyler at firstname.lastname@example.org. This article is excerpted from JustCoding’s Practical Guide to Coding Management.
CDI programs bear the weight of potentially great benefit or potentially great risk for their organizations, depending on the focus and compliance of their query efforts. It is worth mentioning, however, that CDI programs should include input from their facility compliance officer and legal counsel at various stages of implementation and growth.
Ongoing compliance department involvement can help ensure CDI staff structure queries in a compliant manner. Compliance staff can advise the CDI staff members as to whether templated queries are acceptable, too. Such involvement helps ensure that your CDI program meets the doctrine and spirit of the existing regulations.
Since CMS represents the nation’s largest healthcare payer, many CDI programs get their start in conducting record reviews for Medicare patients and/or top diagnosis target areas. However, the goal of improved documentation and patient care should be consistent across payers and disease type, not just improved healthcare documentation for patients who happen to have government insurance.
In addition, the goal of improved documentation and patient care should not focus only on high-cost services such as acute respiratory failure or any other special circumstance. When there is a lack of consistency in policies and procedures, for example, reviewing Medicare and not private payers, the risk for potential misuse and abuse increases.
Editor’s Note: This excerpt was taken from The Physician Queries Handbook by Marion Kruse, MBA, RN.
If you just can’t get enough of former ACDIS CDI Education Director Cheryl Ericson, MS, RN, CCDS, CDIP, consider joining her and fellow speakers Deborah Hale and John Zelem for the 2015 Medicare Compliance Forum in Charleston, South Carolina, October 27-28.
The 2015 Medicare Compliance Forum addresses the ever-changing reimbursement landscape and has six tracks to choose from (three each day), covering Medicare billing and compliance, as well as challenges facing case managers, clinical documentation improvement specialists, utilization review professionals, and more. Here’s a look at the CDI-related sessions being offered.
Document, Document, Document: Enhance Documentation to Drive Meaningful Data
Cheryl Ericson, MS, RN, CCDS, CDIP
Providers need more than just being told to “document” because not all documentation in the medical record is created equal. Most medical records contain pages and pages of words, but much of this text is repetitive and doesn’t translate into meaningful codes, which in turns fails to support medical necessity. This session will take a look at when documentation has meaning by exploring the general concept of medical necessity and its relationship to coded data.
Is Your Readmission Problem Really a Documentation Problem?
Cheryl Ericson, MS, RN, CCDS, CDIP
This session will present an overview of the impact of coded data on CMS quality initiatives, which are also known as pay-for-performance. Participants will be introduced to the CMS quality initiatives of the Hospital Value-Based Purchasing Program, the Healthcare-Acquired Condition Reduction Program, and the Readmission Reduction Program, and how CDI efforts can support accurate reporting of these measures based on administrative data. Key documentation issues associated with the CMS quality initiatives will be presented.
Clinical Documentation Improvement and the Quality Mandate
Deborah K. Hale, CCS, CCDS
Value-based purchasing (VBP) is an important step to revamping how healthcare services are reimbursed in the Medicare program, and it is emerging in the commercial insurance market. Clinical Documentation Improvement for risk adjustment and accurate representation of the patient’s precipitating factors are critical to financial and marketing success. This session will demonstrate Clinical Documentation Improvement targets for risk adjustment and for achieving success with VBP initiatives.
The Role of CDI and the EHR in Supporting Medical Necessity
John Zelem, MD, FACS; Cheryl Ericson, MS, RN, CCDS, CDIP
CDI specialists are often tasked with reviewing the medical record to ensure documentation is comprehensive. However, the use of EHRs can minimize the utility of the health record as documentation often becomes generalized and repetitive. CDI specialists and coders face challenges associated with organizational implementation of meaningful use (e.g., problem lists, computer physician order entry, and the ability of providers to copy and paste documentation). Explore some of the challenges associated with provider documentation resulting from the increased use of technology.
CDI programs bear the weight of providing a potentially great benefit or a potentially great risk for their organizations, depending on the focus and compliance of their query efforts. CDI programs should include input from their facility compliance officer and legal counsel at various stages of implementation and growth.
Ongoing compliance department involvement can help ensure that CDI queries are structured in a compliant manner and can advise the CDI staff members as to whether query templates are acceptable. Such involvement will help guarantee that your CDI program meets the doctrine and spirit of the existing regulations.
Since CMS represents the nation’s largest healthcare payer, many CDI programs get their start in conducting record reviews for Medicare patients and/or top diagnosis target areas. However, the goal of improved documentation and patient care should be consistent across payers and disease type, not just improved healthcare documentation for patients who happen to have government insurance. In addition, the goal of improved documentation and patient care should not focus only on high-cost services such as acute respiratory failure or any other special circumstance. When there is a lack of consistency in policies and procedures, for example, reviewing Medicare and not private payers, the risk for potential misuse and abuse increases.
Editor’s Note: This excerpt was taken from The Physician Queries Handbook by Marion Kruse, MBA, RN.
Dear healthcare professional,
HCPro is currently seeking speakers to present at the 2015 Medicare Compliance Forum, to be held October 27–28, 2015, at the Marriott Charleston in Charleston, South Carolina.
Is that special person you or a colleague?
We seek speakers to present on all aspects of Medicare compliance, case management, utilization review, patient status, and the revenue cycle. Hot topics from the 2014 Medicare Compliance Forum include:
- The latest changes to IPPS and OPPS regulations and their impact on the audit landscape
- What the 2-midnight rule means for patient status and medical necessity
- Changes to observation services and the impact of Condition Code 44 on revenue
- Guidance on Part A to B rebilling
- Implementing policies to receive accurate payment for packaged and separately billable labs
- An update on the current OPPS system and the impact of the new comprehensive APCs on Medicare claims
- Strengthening your utilization review committee by reviewing real-world examples of successful reviews and fully understanding the Conditions of Participation
- Engaging your physician advisors to strengthen your utilization review committee determinations
- Leveraging the expertise of clinical documentation improvement specialists
Note: If you don’t see your hot topic listed here, please write and let us know what expertise you can bring to the podium! Original ideas are welcome.
Submission form and deadline
Please click this link: http://app.keysurvey.com/votingmodule/s180/f/727062/56e6/, complete the form, and submit it to us no later than end of day Monday, March 16, 2015. Please be sure to complete all the fields. Leaving the form open for a lengthy period may cause it to “time out,” so you may wish to draft your submission in a separate word document and paste in the appropriate fields to ensure proper transmission. Speakers are welcome to submit more than one session, but must fill out a separate form for each submission.
HCPro will waive admission fees to the Medicare Compliance Forum for all selected speakers and co-speakers. Conference sessions are typically one hour in length, and selected presenters will be expected to submit PowerPoint materials at a later date.
We look forward to hearing from you! If you’d like more information or wish to discuss a speaking topic, please e-mail Editor Jaclyn Fitzgerald at email@example.com and we’ll set up a convenient time to speak by phone.
Q: What should I do if I see a non-compliant query in the chart? Should I remove it, let my co-worker know, or just leave it in the chart?
A: Addressing non-compliant queries can be tricky. The best course of action would be to share your concerns with your supervisor who can then either confirm your perception of the query being non-complaint or could let you know why he or she feels the query is acceptable. Ask your manager or supervisor to go over any internal query policies to help you better understand your facility’s compliance parameters.
Most facilities have standard query policies and procedures which reflect national standards (such as the 2013 AHIMA/ACDIS “Guidelines for Achieving a Compliant Query Practice” brief). They also have processes in place to help co-workers handle questionable query processes.
If there are no policies and procedures in place (or if you and your coworker are only the two CDI staff querying physicians at your facility) you may want to review the latest query practice information together and approach whatever management team is in place to develop such policies yourselves.
If the query is truly non-compliant, I would definitely want the supervisor to address it rather than you doing so on your own. It may be that the individual needs additional training or it may become a potential performance issue. In which case your manager or supervisor needs to know about the situation and may even need to have a documented conversation with the CDI team member who left the query.
You wouldn’t want to remove the query. The physician may have already reviewed it and responded in his or her progress note. If auditors or internal staff later question where that diagnosis came from, no query trail would exist and you may not be privy to those subsequent questions. If the supervisor or program manager determines the query was indeed non-compliant he or she may need to also circle back to discuss the situation with the physician and/or coding team.
Twenty years or so ago, CDI specialists might have been called record reviewers or had a title associated with “optimizing” the documentation in the medical record. In the course of the MS-DRG implementation and related documentation and coding adjustment payment decreases, CMS indicated in its FY IPPS final rule that there is “nothing inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment… supported by documentation in the medical record.” And so facilities began to formalize the CDI role.
As benevolent a mission as CDI may seem to have, for many facilities the focus of concurrent physician queries continues to be identifying information to increase reimbursement. When such efforts do not reflect the care provided to the patient or are conducted in a leading manner, these practices could be construed as fraud–particularly when data patterns appear to illustrate inconsistencies with national norms.
Of course, healthcare providers must ensure the financial solvency of their organizations, just as government officials must ensure the solvency of their healthcare funding programs. Both sides of this fiscal conundrum face growing financial frustration as both sides continue to search for an underlying cause to answer the dilemma of expanding healthcare costs.
Nevertheless, when a facility submits a claim to the federal government for payment of activities that were never provided, it risks being accused of False Claims Act violations, investigations by the office of the Inspector General and in some cases prosecution by the Department of Justice.
If you haven’t seen the OIG report “Medicare Compliance Review of University of Cincinnati Medical Center [UCMC] for Calendar Years 2010 and 2011,” take a look here at the Office of the Inspector General’s (OIG) website.
What you will see is eye-opening: The OIG reviewed a sample of claims that it deemed were improperly billed by the 695-bed hospital, and, by extrapolating the error rate, determined that UCMC owes more than $9.8 million in improper payments.
The next thing you should consider as a CDI specialist is: How can I prevent my hospital from such a similar (potential) catastrophic review by the OIG? By focusing on affecting positive change in clinical documentation that represents “true” documentation improvement vs. a narrowly defined CDI focus on the capture of CCs/MCCs, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, a manager with Accretive Health in Chicago.
CDI specialists tend to look only at solidifying individual diagnoses in the chart, but often ignore equally important supporting information like clinical indicators to support admission to the facility.
“Do we have good solid documentation of the patient’s DRG, or do we have diagnoses with little clinical support? Are we just sending automatic queries?” he asks. “Often we’re not focused on getting a solid, effective, and encompassing history and physical [H&P] that accurately captures the patient’s history of present illness [HPI] reflective of the patient’s severity of illness, signs and symptoms.”
Physicians tend to elaborate on a patient’s past illnesses vs. a patient’s present illness. A sound HPI consists of a chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present, Krauss notes. “There is often inconsistent or lack of clinical context for the reason for the admission. Doctors need this context for their billing, and [hospitals] need it for quality,” he says.
The advancement of CDI efforts brings with it unique challenges. As benevolent a mission as CDI may seem to have, for many facilities the focus of concurrent physician queries continues to be “optimizing” information in the medical record in order to increase reimbursement. When such efforts do not reflect the care provided to the patient these practices could be construed as fraud–particularly when data patterns appear to illustrate inconsistencies with national norms.
When AdvanceMed Corporation, the Zone Program Integrity Contractor (ZPIC) for CMS parsed its data, it identified eight aberrant providers all essentially from the same healthcare system. After years of investigations and subsequent negotiations between the facilities and the U.S. Department of Justice (DOJ), the facilities ultimately paid an $8.9 million settlement. The DOJ found, in most cases that “the timing of changes in peer comparison data–from below average to above average–coincided with implementation of CDI programs.”
Similarly, when a 2005 Maryland qui tam case settled for nearly $3 million in June 2009, prosecutors pointed to CDI efforts related to leading queries at the crux of the allegations.
Of course, healthcare providers must ensure the financial solvency of their organizations just as government officials must ensure the solvency of their healthcare funding programs. Both sides of this fiscal conundrum face growing financial frustration as both sides continue to search for an underlying cause to answer the dilemma of expanding healthcare costs. Nevertheless, when a facility submits a claim to the federal government for payment of activities that were never provided it risks being accused of False Claims Act (FCA) violations, investigations by the Office of the Inspector General, and in some cases, prosecution by the DOJ.
Editor’s Note: This excerpt comes from The Physician Queries Handbook, Second Edition, by Marion Kruse, MBA, RN.
Q: Our CDI department is developing clarification forms and I have voiced concern with some of the templates. For example, the anemia clarification lists many possible diagnoses including aplastic anemia. If the listed condition would not be clinically acceptable based on the clinical indicators and treatment, should this diagnosis even be listed? I did raise the issue with our physician advisor and he is concerned with the forms, too. Personally, I feel we should not list diagnoses that are not clinically accurate for the specific case.
A: The AHIMA query practice briefs (the latest created in affiliation with ACDIS, Guidelines for Achieving a Compliant Query Practice, published in February) state that “reasonable” diagnoses must be listed in multiple choice queries. With that reference in mind, it is therefore inappropriate to include options on a query that are not supported by clinical indicators.
Although it is good those creating the query templates want to be as inclusive of as many types of anemia as possible, sometimes there is only one appropriate/relevant diagnosis. In such situations, it is okay for the query form to have only one specific diagnosis option as long as the form also includes options for “other,” with a line for comments, and “unable to determine.” The risk with query templates is that there needs to be a way to exclude information not applicable to a particular patient during a specific episode of care; the CDI specialist/coder needs to have the ability to edit/customize the template to suit the situation.
Creation of query templates have many benefits, however.
For starters, they provide a comprehensive starting point for the CDI specialist to work from. In a situation where an anemia query is warranted the CDI specialist could pull up the query template and adapt it to that particular patient’s medical record, including relevant clinical indicators and eliminating inappropriate options.
Furthermore, when CDI professionals include multi disciplinary members in the query creation process such efforts can prove educational for all involved. Physicians can offer clinical, diagnostic insight and HIM professionals may offer insight into coding nuances. Such inclusionary efforts at the outset also help to ensure all vested parties work together. In short, it can help ensure support for the CDI program and its documentation improvement efforts
Hope this helps.