by Kimberly Hoy Baker, JD, regulatory specialist for HCPro
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!
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.
Hospitals continue to report dramatic increases in Recover Auditor (RA) activity, according to results of the latest RACTrac survey released June 4, from the American Hospital Association. The survey found that the number of medical record requests for survey respondents has increased by 53% in comparison to the cumulative total reported in the third quarter 2012.
by Debbie Mackaman, RHIA, CHCO
We’ve been on quite a ride since the start of the Recovery Auditor (RA) efforts. In 2012, RAs continued to expand. This report examines how providers have adjusted their approach in the past year, and it looks forward to some new initiatives and proposals that could alter the state of RAs as a whole.
The Revenue Cycle Institute’s 2013 Recovery Auditor Benchmarking Survey had 325 respondents, representing both small and large hospitals, from all four RA regions. These respondents represented a number of different departments, including compliance, HIM, PFS, case management, and clinical documentation improvement.
The main theme of this year’s survey is the growing state of the RAs, and the fact that they only seem to be gaining speed.
The percentage of providers that have had recoupments from automated reviews rose by 14% this year. In addition, the amount of providers that have seen record requests for complex or semi-automated reviews has increased from 82% to 91%. This may not be shocking, as CMS continues to approve more issues and the scope of the RAs continues to expand, but it highlights the fact that the audits are ever-changing and will force providers to stay on their toes.
Another item providers need to pay attention to is the arrival of the prepayment RA reviews. As of right now, only two issues have been approved—MS-DRGs 312 and 069—with short inpatient hospital stays looming, and only 11 states are in the prepayment demonstration, but that does not mean that providers are unfamiliar with the prepayment review process. According to our survey, 74% of respondents have seen a prepayment review either from their MAC (52%), their RA (6%), or both (16%). A total of 52% said that they are not specifically changing any internal processes related to prepayment concerns but 33% said they’ve heightened awareness in departments affected by RAs. However, almost half of the respondents have felt the need to revise internal processes to meet auditor scrutiny, which appears to be increasing from year to year. As the RA program expands, providers need to be flexible to adjust to current issues and anticipate upcoming reviews.
Another RA-related demonstration project is the Part A to Part B rebilling demonstration. While only 380 hospitals are participating in this demonstration, 28 responded to the survey. Of these, the majority (62%) have been able to rebill and get reimbursed. Only 14% have not rebilled anything yet, but were planning on doing so in the future. This demonstration project will last three years, and although it could assist facilities in recouping some of their costs for inpatient stays that were deemed not medically necessary, it is certainly not an answer to resolving the daily operational issues facilities face.
The third recent development is the complaint filed by the American Hospital Association (AHA) against RAs. As you all probably know, the AHA, along with several other hospitals, issued a lawsuit against the RAs for unfair Medicare practices. Based on this bold move, I was curious what respondents thought about the initial action. Sixty percent think that something will happen as a result of the complaint, but 43% of those think that it will only involve very minor changes. On the other side, 17% think that nothing will happen, while 25% are just happy to see the RAs being called out on their current practices. This will be an interesting topic to follow and may set a precedent for other audit processes. Although respondents appear to be pessimistic regarding the potential outcome of the lawsuit, the fact that RAs are being challenged should give providers hope for changes going forward.
Editor’s Note: Debbie Mackaman, RHIA, CHCO, is a Regulatory Specialist with HCPro, Inc., and teaches its Medicare Boot Camps. This post is an excerpt from the benchmark report. To read the entire report, visit The Revenue Cycle Institute.
ACDIS sister publication and network the Revenue Cycle Institute is conducting its annual Recovery Auditor Benchmarking survey to determine how facilities nationwide are handling this intricate auditing and denials management process. The survey explores experiences with Recovery Auditors and inquires about plans your facility has put into place to deal with them. It covers new developments, such as prepayment audits, Medicaid RACs, Part A to Part B rebilling, and much more.
ACDIS understands that many CDI professionals also play an important role in managing Recovery Auditor record requests as well as in denial management processes. We value your input and appreciate your time and effort in completing this anonymous survey. We know you must be as interested as we are in finding out what your peers are doing to handle the Recovery Auditor process, so all of this data will be compiled and shared with you in an upcoming report.
To take the short survey, please click here.
The fight over medical necessity continued last week as the American Hospital Association and its four co-plaintiffs asks courts to “expedite” a lawsuit against U.S. Department of Health and Human Services (HHS) for unfair Medicare practices pertaining to the Recovery Auditor program.
According to a motion filed in Washington, D.C., December 13, the crux of the issue is this: Recovery Auditors second guessing physicians’ right to make decisions regarding where to best provide patient care. It suggests that Recovery Auditors “examine cold paper records and determine—at an alarming rate—that the physicians were wrong and patients should not have been admitted to [the] hospital,” the motion states.
Recovery Auditors collected $2.29 billion in overpayments in fiscal year (FY) 2012, according to CMS’ November report. The top concern listed for three of the four Recovery Auditors was medical necessity for cardiovascular procedures. The fourth was for medical necessity related to admissions for minor surgery. The latest recoupments represent a staggering increase of nearly three-times more than FY 2011, according to an article in Fierce HealthCare. (A November 27 report from the Office of the Inspector General indicated it expected some $6.9 billion in total fraud and related HHS recoupments.)
Determining where to best provide care and understanding Medicare’s rules and regulations surrounding payment for that placement continues to be difficult issue for many facilities. A recent 60 Minutes investigation “Hospitals: The Cost of Admission”, focused on admission practices of the 70-hospital for-profit Health Management Associates Inc. The news report alleged the chain pressured physicians to admit a set quota of patients in order to receive increased reimbursement for the services provided. Despite the company’s denial of the allegations its stocks fell sharply following the report.
Nevertheless, the AHA states that CMS is illegally withholding funds. Its motion “seek(s) an expeditious resolution … because … the nation’s hospitals, are being harmed on an ongoing basis by an arbitrary government policy: [CMS] has refused, and is still refusing, to pay the nation’s hospitals for hundreds of millions of dollars’ worth of medically necessary care that they provide to Medicare beneficiaries,” the report states.
Editor’s Note: This article was originally published in the December 20, 2012 edition of CDI Strategies.
Some feel establishing goals based solely on reimbursement leads to compliance concerns. Others assert accurate documentation of the care a patient receives naturally leads to improved reimbursement and tracking it just helps support the need for the CDI program. Regardless, the financial return on a facility’s investment in its CDI staff is undoubtedly beneficial information to help prove the value of the CDI program, especially in the current healthcare environment where every expense and departmental budget is scrutinized.
Conveying the financial benefits of CDI can be fairly easy; the addition of a single complication or comorbidity (CC) or major CC (MCC) can shift the designation of patient care into a higher weighted diagnosis related group (DRG), thereby increasing a facility’s reimbursement by thousands of dollars.
For example, if a patient who suffered a heart attack requires surgery for a pacemaker and lead implant the principal diagnosis would be coded 410.01, acute myocardial infarction of other inferior wall, initial episode of care, and the procedures would be coded 37.72 (initial insertion of trans venous [pacemaker] leads [electrodes] into atrium and ventricle) and 37.83 (initial insertion of dual-chamber [pacemaker] device). At the time of admission, the patient is noted to have a history of congestive heart failure (CHF) and the chest x-ray in the emergency room showed venous congestion, which improved after the administration of Lasix intravenous push (IVP). The medication record indicates Lasix 40 mg IVP was given twice in the emergency room.
The figure below illustrates how different ICD9-CM codes roughly translate into MS-DRG codes and the estimated payment changes associated with such differences.
Employ caution, however, when illustrating the CDI program’s affect on reimbursement. While improved capture of clinical documentation may increase reimbursement, it may not always do so, and creating a CDI program for financial gain cannot be the program’s only purpose. Money earned from inappropriate means today is simply money taken back–with interest–by the government later.
Editor’s Note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition, by Marion Kruse, MBA, RN, and Heather Taillon, RHIA.
|428.0, Congestive heart failure, unspecified||244, Permanent cardiac pacemaker implant w/o CC/MCC||$11,510|
|428.0 and 428.32, Chronic diastolic heart failure||243, Permanent cardiac pacemaker implant w/CC||$13,728|
|428.0 and 428.33, Acute on chronic diastolic heart failure||242, Permanent cardiac pacemaker implant w/MCC||$17,554|
Editor’s Note: Join Krauss and Shailesh R. Virani, MD, for the July 17 webinar “Outpatient CDI: A Proactive Approach
CDI specialists can increase their value to their hospital and ensure a far greater degree of physician buy-in through serving as a pro-active denials management specialist. In some respects CDI specialists already serve as a denials avoidance agents, playing an active role in changing in patterns of physician documentation to reduce the likelihood of medical necessity denials.
A major role of the CDI specialist is to ensure proof of medical necessity. This does not necessarily mean that CDI specialists should become quasi- case managers. However you cannot perform CDI in a vacuum, either. Getting a physician to document a diagnosis through a query without obtaining supporting documentation—including an accurate picture of patient’s history of present illness, physical findings, abnormal lab and radiology tests, and the physician’s clinical judgment and medical decision-making employed in arriving at a diagnosis or differential diagnoses—will likely result in a denial, and a take-back of the diagnosis by an auditor.
Therefore, what CDI specialists should focus upon is obtaining documentation in the history and physical (H&P) to support the severity of the patient’s signs and symptoms. The H&P must demonstrate the patient’s risk of mortality and the likelihood of an untoward event. That means each H&P should contain:
- A chief complaint that reflects the patient’s true chief complaint. This does not mean a definitive diagnosis like stroke, pneumonia, or sepsis (have you ever heard of a patient who comes in and says they have sepsis?) The chief complaint is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. What is the patient’s problem, in their (patient’s) own words? Examples include “patient complains of upset stomach, aching joints, and fatigue.” In general the medical record should clearly describe the chief complaint and nature of patient’s presenting problem.
- The patient’s associated signs and symptoms, and the amount and complexity of comorbid conditions reflects the additional amount of physician work performed in managing these conditions.
- A history of present illness (HPI) with at least four elements. There should be a direct correlation between the HPI and the assessment. You should be able to trace back the physician’s assessment and impression outlining clinical diagnoses and plan of care to the patient’s presentation and nature of presenting problem as described in detail within the HPI. The documentation should clearly paint the picture of the patient’s severity of illness and necessary intensity of service.
Recovery Auditors are not just checking for accurate coding but validating diagnoses for clinical reasonableness. Consider if a physician provides the following documentation in his or her assessment of a patient with likely sepsis:
Patient had a temperature of 103 degrees with a white count of 20 with 10 bands. Initially patient seen in my office last week with subjective fever, chills, and general malaise. Prescribe course of antibiotics but now presents to the emergency room with worsening cough, fever, weakness, somewhat change in mental status from her baseline of mild dementia. Patient looks like they have a UTI from the urinalysis in the ED, likely has sepsis with potential pneumonia with a positive chest x-ray. Will need a course of IV antibiotics due to failure of outpatient antibiotic treatment to see if we can prevent a re-occurrence of previous hospital admission four months ago where patient developed a deep seated UTI with sepsis that was resistant to IV antibiotic treatment and had a rocky course in the hospital.
Are you going to question the medical necessity of the admission? It’s also far less likely that a Recovery Auditor or other Medicare contractor will second-guess the physician’s clinical judgment in determining the appropriateness of inpatient admission versus observation.
Here are some more tips to consider when performing your record reviews:
- Review the entire record. Start with the ER notes from the time the patient arrived in the ambulance to see what brought them to the hospital. Review the H&P to make sure the physician documented that the patient was truly sick (watch out for “point and click” electronic documentation prompts, as these don’t provide evidence of the doctor’s medical decision-making). We need to be able to tell the physician to come up with a couple sentences that captures their thought processes as to how they came up with the diagnosis.
- Wear your nursing hat. Do you see a sick patient? If you don’t see a sick patient in the documentation, ask what is missing. Is the HPI deficient? Is the physical exam not thorough? Is the past, family, social history (PFSH) not thorough? If a doctor is thinking MI in a 55-year-old Medicare patient with chest pain, and the patient has a strong family history of early MI, that certainly changes the picture.
- Educate your physicians one-on-one. If you review the nursing notes and see that a patient was breathing 40 times per minute and was so short of breath that he couldn’t walk across the room, and upon arrival at the hospital his P02 was 45 and PC02 was 60, with a ph of 7.25, but the doctor writes in his H&P “patient seen in the exam in no apparent distress,” that’s a good place for one-on-one education. Tell the doctor, “I looked at the ER documentation and it looks like a different patient between yours and the ER doctor’s. What are your thoughts on how sick the patient was?” The doctor should be writing, “The patient is not in respiratory distress at this time, but presented in obvious respiratory failure upon presentation to the ER.” The patient may not be in respiratory failure now, but he certainly was, and that’s of concern to the doctor and reflects part of his medical decision making in admitting the patient to the hospital for close workup and further management.
Remember that CDI is intended to represent Clinical Documentation Improvement—improving documentation of the patient’s clinical picture throughout the record—and not strictly RDI (Reimbursement Documentation Improvement). In this day and age of the Recovery Auditors, obtaining documentation for diagnoses alone simply isn’t enough.
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.