All Entries Tagged With: "RAC"
Guidance on documentation requests, queries, and late entries in the record
Lynne Spryszak, HCPro’s CDI Education Director, was one of several speakers offering great information during yesterday’s ACDIS members’ Quarterly Conference Call. She mentioned a November 2011 CMS publication about documentation requests that can have a direct impact on provider requests. Here is the link:
http://www.cms.gov/manuals/downloads/pim83c03.pdf
Lynne also provided more information from the Medicare Benefit Manual:
3.3.2.5 – Late Entries in Medical Documentation
(Rev. 377, Issued: 05-27-11, Effective: 06-28-11, Implementation: 06-28-11) This section applies MACs, CERT, Recovery Auditors, and ZPICs, as indicated.
“A provider may discover that certain documents were misfiled or needed to be filed in the medical documentation during the process of responding to an ADR. Providers are encouraged to add to the medical record or notes file all relevant documents that were created at the time of service or within a few days of the date of service.
“The MACs, CERT, Recovery Auditors, and ZPICs shall give less weight when making review determinations to documentation, including a provider’s internal query responses, created more than 30 calendar days following the date of service. If the MACs, CERT, or Recovery Auditors identify providers with patterns of making late (more than 30 calendar days past the date of service) entries in the medical documentation, including the query responses, the reviewers shall refer the cases to ZPIC and may consider referring to the RO and State Agency.”
Thank you, Lynne!
WWRD: What would the RAC do?
RAC focus areas need to be on your CDI program's radar screen but it need not take over your program's focus.
There has been much discussion based on what Recovery Audit Contractors (RAC) and other state and federal regulatory bodies are doing or what their next move will be (though does anybody really know?!?).
We’ve all heard the stories of denials of well documented and clinically substantiated conditions; of the role the RAC reviewer incentive structure plays in RAC determinations, of confusing correspondence addresses, etc. Whether or not the stories are true doesn’t matter as much as the attention such stories garner. We’ve also heard of the fear that prevails and this makes me wonder about the effect of these reviews on our day-to-day workflow.
I recommend we stop, take a deep breath, and think…Why not switch our focus from “what would the RAC do” back to what care was provided and how was it documented in the medical record?
Now, I’m not saying we should ignore RAC, or forget that they are there. Believe it or not, they do keep us grounded. I’m just saying let’s try not to make them the focus. Let’s try not to work according to the WWRD principle.
We are currently in the midst of a nationwide movement toward quality and public reporting. It is commendable that our national focus has turned to the quality of healthcare. And providing quality care is all about doing the right thing at the right time. If we stay true to who is at the center of this movement, ‘the patient,’ and set the stage for the right process to ensure that we do the right thing at the right time, good outcomes will prevail.
Let us take that thought and apply it to the world of CDI. The concurrent process of CDI, in and of itself, takes place at the ‘right time,’ while the patient is still in the hospital and we have all the necessary medical record, laboratory, and dietary information available to us. Through our consistent, thorough review of the information contained within the record we can help clarify ambiguous information, identify potentially omitted diagnoses, and ensure the record accurately captures all the clinically relevant care provided.
Although our task can be complicated, we have available to us several documents that assist us in our endeavors to do the ‘right thing:’ ACDIS’ Code of Ethics, AHIMA’s 2008 practice brief, Managing an Effective Query Process, the 2010 document, Guidance for Clinical Documentation Improvement Programs, and their 2010 publication, Clinical Documentation Improvement Toolkit. In order for our day-to-day CDI practices to be able to withstand audit scrutiny we must use these guidances, plus our own facility-specific policies and procedures to guide us.
When we stray from our ethical and moral core, and away from the guidelines in place to protect us, we could find ourselves alone and exposed. There have been several discussions (most recently during the November 17, 2011 ACDIS Quarterly Membership Conference Call) regarding the dangers of leading queries and the potential legal implications involved. We all need to operate within the guidelines and be prepared to stand up and defend the information contained within the medical record.
If we center our attention on doing the ‘right’ thing, focus on our responsibility to the patient, and continue to assist in the precise and complete representation of the patient encounter within the medical record, we will have done our job, and possibly kept the RAC at bay. Let us do what we do best, according to the guidelines, and let the policies and procedures that are in place steer us on the right path.
Don’t think about what RAC would do; think about doing the right thing at the right time for the patient.
Santa’s not the only one watching to see if you’ve been bad or good
Singing: He sees you when you’re sleeping. He knows when you’re awake. He knows if you’ve been bad or
What will the jolly old elf will bring to the RAC offices?
good, so be good for goodness sake.
Remind you of anyone? No? Here’s a hint. It rhymes with knick-knack but these groups aren’t known to be particularly “nice.”
Audit contractors (Recovery Audit Contractors or RACs) are not Santa, but they are watching you, and they certainly know if you’ve been naughty.
Let’s be realistic, all of your facility healthcare data is being scrutinized, analyzed, and compared. Statistical data gives audit contractors an idea of which hospitals fall off the bell curve, and what diagnosis qualify as low hanging fruit.
If your hospital has a 30% sepsis admission rate and all other hospitals in your area have a 10% rate, then you pretty much are going to stand out like a sore thumb. Do not fool yourselves. It is not because your CDI department is that much better at capturing sepsis as a diagnosis.
Take a look at how your facility does business and whether it may be pushing the envelope when it comes to leading queries and creative coding. Does your hospital follow AHIMA’s recommendations when it comes to formulating compliant queries? The brief clearly states that:
“Individuals who perform the query function should be familiar with the AHIMA Standards of Ethical Coding, which direct coders to assign and report only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines.”
Next, review and update your own internal policies and procedures. Many hospitals create these policies and then never check to make sure the rules are being followed. The AHIMA guidance states:
“Individuals performing the query function should follow their healthcare entity’s internal policies related to documentation, querying, coding, and compliance, keeping in mind that data accuracy and integrity are fundamental HIM values. Only diagnosis codes that are clearly and consistently supported by provider documentation should be assigned and reported. A query should be initiated when there is conflicting, incomplete, or ambiguous documentation in the health record or additional information is needed for correct assignment of the POA indicator.”
Lastly, create an audit process to ensure that both your own policies and AHIMA recommendations are being followed. Healthcare entities should consider establishing an auditing and monitoring program as a means to improve their query processes. They can consider several methods for this ongoing process. Queries can be reviewed retrospectively to ensure that they are completed according to documented policies. This might include reviewing determining whether the:
- query was necessary
- language used in the query was not leading or otherwise inappropriate
- query introduced new information not otherwise included in the medical record
Based on the results of this review, the healthcare entity may need to identify specific corrective actions. For example, any cases identified as containing inappropriate queries which resulted in inaccurate code assignment will require corrective action and possibly rebilling. Inappropriate queries should be tracked, trends identified, and appropriate education, training, and/or disciplinary action taken when warranted.
No one wants to get a lump of coal in their stocking. And no one wants to give the RAC or other auditor a Christmas bonus. Take time this holiday season to make some New Year resolutions and ensure that your facility is compliant and knowledgeable. You will then reap the rewards of a stocking filled with peace of mind.
AHA report shows 77% of RAC denials overturned
Latest report shows RAC denials are being overturned.
Interesting news bites from the American Hospital Association (AHA)… according to more than 2,000 hospitals responding to the AHA’s latest RACTrac survey, hospitals are appealing nearly a third of all RAC denials and 77% of those were overturned in favor of the provider.
The survey also reveals that medical necessity denials are the top reason RACs have denied claims since first-quarter 2010, and that the majority of these medical necessity denials were for one-day stays found to be in the wrong setting, not because the care was medically unnecessary.
The latest RACTrac report reveals that 57% of hospitals report that they have yet to receive any education related to avoiding payment errors from the CMS or its contractors.
Want to know more? Attend the AHA’s free webinar on January 4 to hear an update on the RAC program and review the survey results. Register at https://www1.gotomeeting.com/register/533318961 . For information, visit http://www.aha.org/advocacy-issues/rac/ractrac.shtml.
Asset or Liability: How do you describe your CDI program?
A recent discussion on the ACDIS CDI Talk list serve provoked me to ponder: Is your program truly an asset
Don't use measuring tape to determine your CDI program success.
to your organization? Does it promote complete and accurate clinical documentation reflective of patient severity of illness (SOI), medical complexity and quality outcomes that justify the costs of care? Or is your program really a liability to the organization?
The CDI Talk discussion asked how programs calculate their return on investment (ROI). One response pointed out that any monthly report of CDI case mix change and financial reimbursement effectiveness must include a disclaimer informing readers about the fact that such data is subject to adjustment for transfer DRGs provisions inherent in the inpatient prospective payment system (IPPS). So, here’s my two-cents on the issues raised.
Another adjustment to consider
An effective CDI program can be a significant asset or a significant liability depending upon how the program is initially structured, set up, rolled out, and carried forward with daily CDI activity. Unfortunately, a majority of CDI programs center their metrics (proof of their ROI) on increased financial reimbursement to the hospital. This takes away from the overall potential of the CDI program for the hospital as well as the physicians. That’s because this narrow focus on reimbursement positions CDI programs as revenue enhancement programs. It forces CDI specialists to focus on the capture of CCs/MCCs and “more specific” principal diagnosis. And this, in turn increases risk and liability for the hospital.
Consider the following common analysis conducted by CDI programs to prove their effectiveness:
- Number of queries left by the CDI
- Number of queries that change the principal diagnosis
- Number of queries that add a CC/MCC
- Number of physician queries responded positively to by the physician
- Number of physician queries not responded to by the physician
- Number of queries left in the record which the physician did not agree to clarify/add documentation
- Potential capture rate of monthly CC/MCC not obtained due to physician disagreement
- Change in monthly case-mix-index
- Time from admission until record was reviewed and DRG worksheet completed
- Average number of times a record was reviewed per admission
While reviewing these statistics can provide insight into a CDI program’s success, commitment to these types of matrices as the sole indicators of a program’s success can stymie a program.
A primary goal of CDI professionals is to improve overall clinical documentation in the record for purposes of accurate, concise, and effective reporting of patient acuity/SOI, physician clinical judgment, medical decision making, and resource consumption through specificity in documented diagnoses.
One of many “by-products” of this stated goal of CDI is that the resulting reimbursement more closely approximates the care provided. However, strict focus on financial reimbursement benchmarks creates incentives for staff to omit queries that don’t affect payment or increase queries for conditions that do. This, ultimately, artificially creates a rosy ROI picture for the CDI program. It also increases financial risks as auditors data mine, down-code, deny, and ultimately take back reimbursement from erroneously documented and coded cases.
Now you see it, now you don’t
In my experience, many a RAC denial is fundamentally related to CDI program deficiencies. Often a query results in the physician documenting a diagnosis in the record just once. The query may have asked the physician to clarify the principal diagnosis, secondary diagnosis, or sought to add a CC/MCC to the record.
These queries frequently include:
- Aspiration vs. community acquired pneumonia
- Sepsis with change in mental status vs. sepsis with acute encephalopathy
- COPD exacerbation with hypoxemia vs. COPD exacerbation with acute-on-chronic respiratory failure
The physician may respond to the query by including the specified diagnosis or diagnoses in his/her next progress note yet not include these same diagnosis specificity in the continued care progress notes and discharge summary. According to our previously discuss benchmarks, the CDI manager counts the physician’s response as a “win,” and moves on to the next chart review.
The physician’s conclusory diagnostic statement without accompanied discussion of pertinent clinical facts and information constitutes insufficient documentation from an “outsider’s review” perspective. The RAC or other third-party payer retrospective reviews frequently down-code or deny these claims due to such documentation deficiency.
Effective CDI programs should incorporate more than financial measures in their program benchmarking. Clinical documentation beyond mere diagnostic conclusory statements supporting clinical presentation of the patient as well as the clinical facts of the case is essential for revenue integrity and continuity of care. Consider the following found in the most recent Statement of Work for the RAC:
“Clinical validation is a separate process, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented. Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder.”
Now is an ideal time to consider your answer to the “asset vs. liability” dilemma, take inventory of the processes of your CDI program, and aim for positive process changes in the new year to ensure your program’s contribution to the healthcare organization.
One may wish to determine how many RAC denials were associated with disallowance of principal or secondary diagnoses (CC/MCC) on the basis of insufficient documentation. The continued success of the profession of CDI is predicated upon adapting to changes in the healthcare marketplace. Renewed emphasis on a “visionary” mindset versus complacency will ultimately govern the true success of your CDI program.
Complete and accurate clinical documentation is the future of healthcare
What can you can do to improve your program? How can you put some of your CDI strengths into better practice and re-examine your
Hospitals need to get their clinical documentation in order now.
weaknesses to determine what you can do to tweak it and make it a more successful program? There are numerous opportunities for program improvement every day. Let’s look at a few of the common areas of CDI program improvement begin practiced today.
For many years, many programs were driven by what we did from a Medicare and reimbursement perspective. When you look at what is currently best practice in the documentation world, it really is about addressing documentation for more than just financial issues. We want to make sure that we capture the true severity of illness (SOI) of the patient. We want to know which conditions were present on admission (POA) and how the patient’s care progresses through to discharge. It is all this documentation that helps to determine the final payment, the determination of the final DRG, and it is going to determine what the hospital and physician profiles on a variety of measures.
Certainly, medical necessity is driven by what is documented, and when we have clarity and consistency in documentation, CDI programs can impact length of stay concerns, also. If the CDI program includes all these concerns, and we have clear documentation for all of the conditions that were treated while the patient was in the hospital, then you’re going to be compliant, and it’s going to help you avoid being audited by not only by RAC, but whatever other auditing body may want to review any of your records.
When you look at what truly is the line of severity, or the line of SOI as I like to call it, you’ll see that what we’re really trying to do through documentation improvement is ensure that all of the conditions being treated are clearly and appropriately identified. In other words, we all know that there’s a little bit of a discrepancy in the language and wording used in the medical world as opposed to the language used on the coding side. It is (was) this discrepancy that was kind of why we all started having CDI programs in the first place.
You don’t want to over-document conditions that aren’t really being treated. You don’t want to have the facility reimbursed for care that wasn’t part of the patient’s clinical picture. Conversely, you don’t want to have situations arise where, because of the inaccuracy or lack of specific documentation, you lose the opportunity to get the appropriate codes, get the correct patient profile, and get the right reimbursement.
Take that just a little step further. Appropriate documentation of the SOI of the patient is going to support quality and core measures scores as well. Those are the pieces of the documentation that then drives profiling and they are the pieces of documentation that impact where the case mix index goes, the average of all those relative weights of all those DRGs required to support the appropriate length of stay, and that too gets reflected in hospital and physician profiles.
As we look to the future of healthcare and how facilities and physicians are reimbursed, and what’s happening with their payment structure, it’s becoming more and more clear that there’s going to be some comparison between what’s happening in the hospital and the documentation in the hospital, and what the physician might be billing for that visit.
We want to make sure that the documentation those are as accurate as possible to compliantly get what we deserve and support where we are billing.
Editor’s Note: This post was excerpted from the audio conference “Clinical Documentation Improvement: Strengthen your program and protect against denials,” presented on Thursday, January 27.
Q&A: Keeping electronic query copies
Q: Our program does not typically include query information as part of the medical record. If the physician responds to a faxed query,
You've got questions? We've got answers. E-mail mvarnavas@cdiassociation.com
we scan the fax into our electronic record. However, we resolve most queries in person or through a secure messaging system in our EMR (we use EPIC). Once the physician updates the chart, or replies back explaining his/her disagreement to the query, the query is considered “done” and we close the chart. The secure messaging system could be audited, if need be, but is really considered outside the chart. Should we be concerned about this or change our practices at this point due to additional auditor scrutiny?
A: If you’re using a messaging system for querying, I would just caution you to ensure that the provider is actually adding the necessary clarification to the progress notes or other part of the record. Also, beware of responses on a fax or other query form if that is the only place the physician clarifies the documentation. The RACs seem to tend to deny those diagnoses since they appear only once or twice and are often omitted from the discharge summary. Many of the RACs are now denying diagnoses that are not included in the discharge summary. Sure, it is not fair, or even representative of the coding rules, but then who’s to stop them?
Editor’s Note: Lynne Spryszak, RN, CPC-A, CDI Education Director for HCPro Inc., Danvers, MA, answered this question. Contact her at lspryszak@Spryszak teaches the CDI Boot Camp and its online version.
Expanding the CDI Horizons: Practical Considerations
If you look at the center of this illusion it looks like the circles at the corner are expanding. Expand. That's what you want to do with your CDI program.
In my last blog titled Identifying Missing CDI Elements by Expanding Our Horizons, I extolled the virtues of identifying patient medical necessity for inpatient hospitalization and the potential vital role CDI specialists play in working with case management (CM) and utilization review (UR)/management staff.
In this blog post I will focus on offering practical considerations to how to integrate our role as change agents into the daily chart review process.
CDI staff and determination of medical necessity
Clinical documentation serves a number of people and purposes such as:
- Appropriate ICD-9 code and MS-DRG assignment
- Clinical outcome studies
- Reporting of risk adjusted severity of illness
- Readmission as part of the proposed Hospital Value Based Purchasing program
- Quality and efficiency care provisions under proposed rules for Accountable Care Organizations
CDI specialists are also frequently asked to help establish medical necessity for patient admission as well as the medical necessity for a patient’s continued stay in the facility. All of these items depend on clear, concise, accurate, and relevant clinical documentation. I suggest that, as a profession, we stand to expand our presence and elevate our stature in the entire process. [more]
Q&A: Querying for SIRS when clinical indicators are present
Seems there's no end to questions about the difference between SIRS and sepsis. Here's a brief reminder from Dr. Gold.
Q: Is systemic inflammatory response syndrome (SIRS) an inherent part of an infection? For example, when a patient comes in with pneumonia, and clinical indicators are present for SIRS but the physician did not specifically write SIRS, should coders or CDI specialists query physicians?
A: SIRS is a response by the body to dead or injured cells. It is inherent in infections and should not be sought after when the condition is an obvious infection. Pneumonia, for example, is an obvious infection.
Certain advice from coding authorities has CDI specialists/coders to lead physicians down the garden path of identifying and documenting SIRS whenever a patient has two of the four criteria described in the Journal of Critical Care Medicine. However, the criteria for SIRS referenced in the article were actually established in 1992 as part of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. The conference concluded that the manifestations of SIRS include, but are not limited to:
- Body temperature less than 36°C or greater than 38°C
- Heart rate greater than 90 beats per minute
- Tachypnea (i.e., high respiratory rate) with greater than 20 breaths per minute and/or an arterial partial pressure of carbon dioxide less than 4.3 kPa (32 mmHg)
- White blood cell count less than 4000 cells/mm3 (4 x 109 cells/L) or greater than 12,000 cells/mm3 (12 x 109 cells/L), and/or or the presence of greater than 10% immature neutrophils (band forms)
But soon CDI specialists/coders started to query physicians about SIRS when only a couple of the aforementioned criteria were present regardless of how sick the patient was and regardless of whether vital sign changes were even related to the identified infectious process.
Overcoding SIRS leads to inappropriate billing, not to mention the potential for RAC recoupments and tremendous penalties if identified by the Office of Inspector General.
When a patient has sepsis (ICD-9-CM code 038.xx), the patient has sepsis.
The 2001criteria for sepsis from the Journal of Critical Care Medicine emphasizes that. It states that the patient has to be truly sick from the infection. If the patient does not have sepsis in the face of an infection, the presence of SIRS is implied.
Virtually all patients with acute appendicitis meet the criteria for SIRS, and it’s only the rarest cases of appendicitis that have sepsis. Most patients with bacterial pneumonia exhibit signs and findings of SIRS, but most receive outpatient treatment and do not have sepsis.
Editor’s Note: This article first appeared on JustCoding.com. Learn more about the difference between sepsis and SIRS in the following articles:
Medicaid RACs are coming…someday
CMS has instructed Medicaid agencies to develop Medicaid recovery audit contractor (RAC) programs; however, the implementation date remains unknown.
CMS sent an October 2010 letter to state Medicaid directors, requiring state agencies to submit their plans for RAC
CMS put an indefinate hold on Medicaid RAC implementation in February.
implementation or request an exemption. CMS also said in the letter that it expects the Medicaid RAC programs to be fully implemented by April 1, 2011. However, a February bulletin has suspended that deadline indefinitely.
The bulletin states that the April 1 deadline did not give state agencies enough time to address operational issues to ensure compliance with provisions of the final rule, which is yet to be published. CMS plans to issue the final rule later this year and will indicate the new implementation deadline at that time.
In the meantime, you can find out which states have submitted their Medicaid State Plan amendment (SPA) to CMS, at the CMS website. SPAs address the essential elements of the state’s RAC program. To date, all U.S. states and territories have submitted SPAs.
Editor’s Note: This post was originally published on our sister blog Case Management Mentor, on Tuesday, March 1.
