Jan

30

Understand the intricacies of medical necessity

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Notwithstanding any other provisions of this tile, no payment may be made under Part A or Part B for any expenses incurred for items or services, which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Screening criteria such as Interqual Level of Care and Millman Care Guidelines are intended merely as screening guidelines, are not dispositive on the issue of existence of medical necessity with respect to any particular claim, and do not eliminate the need to utilize independent clinical judgment when reviewing claims. Further, these criteria reflect clinical interpretation and analyses, and cannot alone provide the sole basis for definitive decisions.

Editor’s note: Krauss is a senior coding and chargemaster consultant for QHR in Brentwood, TN. This information was adapted from a January 14 article in JustCoding.com.

Jan

30

Q&A: RAC information for long term care facilities

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Q: Most of the RAC information I have seen has been geared to the hospitals, and rightly so. But do you have any details of what items RACs focused on for nursing homes in the demonstration project? Do you know of a place where I can find out more information on this topic?

A: It appears that long term care facilities will undergo the same type of RAC reviews that the acute care hospitals are undergoing. From what I’ve seen, the focus appears to be medical necessity of the stay, documentation and coding/claim data for reimbursement. RACs haven’t done much work in this area yet, but it appears that they are definitely beginning to fish for an error rate to find out how much money may be out there. Consider the following January 5 article from the American Hospital Association Web site:

CMS recently announced that it has awarded contracts to AdvanceMed and Wisconsin Physician Services (WPS) to perform medical necessity reviews of long-term care hospital (LTCH) admissions, as required by the 2007 Medicare, Medicaid and SCHIP Extension Act. AdvanceMed will perform LTCH sampling and validation while WPS will review claims, using existing inpatient hospital review criteria, to determine a national error rate. CMS indicated that work will begin later this month.

This suggests that long term care facilities need to begin the same type of data mining and gap analysis that the acute care facilities are performing. Long term care facilities should evaluate their admissions to ensure they are meeting medical necessity criteria, evaluate their documentation for completeness and look at their claims data to ensure that the documentation and billing are in sync. CMS will be right behind them.

Editor’s note: RAC Report Advisory Board member, Tanja Twist, MBA/HCM, director of patient financial services for Methodist Hospital in Arcadia, CA, answered this question.

Jan

30

Take note: 10 RAC facts to consider

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Consider the following 10 RAC facts:

1. RAC must send only one review result per claim (e.g., coding and medical necessity review must be in same letter) 
2. RAC must report potential fraud immediately 
3. RAC must report potential quality issues 
4. RAC may receive “tips” from CMS, affiliated contractors, Office of Inspector General, law enforcement or other agencies 
5. Recoupment is through current or future Medicare payments 
6. Provider can repay through installment plans up to 12 months, or longer with approval 
7. Debtor (e.g., hospital or healthcare provider) can present RAC with settlement offer 
8. RACs will receive smaller fee if providers voluntarily self-report after receiving a medical record request or demand letter 
9. RAC must provide a toll-free customer service number to all providers 
10. RAC shall provide the CMS project office with all correspondence containing complaints

Editor’s note: These facts were provided by Linda M. Fotheringill, Esq., of Washington & West, LLC, in Baltimore, MD, during the January 6 HCPro, Inc., audio conference, “RAC Readiness: Develop an Effective Audit Tracking System.” To listen to the audio conference, visit www.hcmarketplace.com/prod-7371.html.

Jan

30

Q&A: RAC automated reviews

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Q: Under what circumstances can a RAC make a finding that an overpayment or underpayment exists without requesting medical records?

A: RACs may use automated review (where no medical record is involved in the review) only in situations where there is certainty that the claim contains an overpayment. Automated review must meet one of the following criteria:

• Have clear policy that serves as the basis for the overpayment (“clear policy” means a statute, regulation, National Coverage Determination, coverage provision in an interpretive manual, or Local Coverage Determination that specifies the circumstances under which a service will always be considered an overpayment)
• Be based on a medically unbelievable service
• Occur when no timely response is received in response to a medical record request letter

Editor’s note: This Q&A was excerpted from the CMS Web site. For additional RAC Q&A, click here.  

Jan

30

Tip: Hire a physician liaison to jump-start your RAC efforts

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by Glenn Krauss, RHIA, CCS, CCS-P, CPUR

One item that appears to be missing from most HIM directors’ RAC preparation checklist is a root-cause analysis of the contributing factors to RAC denials (i.e., whether they are rooted in medical necessity, coding, or both).

Although some argue that RACs arbitrarily deny clinical cases with little appreciation of clinical standards of medicine and evidence-based medicine, it can certainly be said that hospitals contribute to self-inflicted denials through woefully inadequate patterns of nursing and physician clinical documentation. This inadequate documentation begins in the ER and pervades the patient’s entire visit. Instituting a RAC response infrastructure that includes a root-cause analysis is essential.

Using a physician liaison in the coding and case management/utilization review process first became popular during the 1990s, as hospitals quickly recognized the direct benefits of a properly structured physician liaison program.

However, with time, the merits and value of such a program fell out of favor primarily due to budget cuts and fewer hospital dollars available for discretionary programs or initiatives. Today, however, physician liaisons are back on the scene and more important than ever.

A well-trained physician liaison is instrumental in not only developing action plans to address process deficiencies, but he or she can also implement these deficiencies in an effective and efficient manner.

An effective physician liaison can provide education, instruction, and training to physicians about their role in consistently demonstrating medical necessity through succinct medical record documentation.

Editor’s note: Krauss is a senior coding and chargemaster consultant for QHR in Brentwood, TN. This tip was excerpted from the January 2009 issue of the HCPro, Inc., newsletter Medical Records Briefing.

Jan

30

Tip: Stay on top of common coding pitfalls

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• DRG 186–187—Pleural effusion with complication/comorbidities(CC) or major CC (MCC)
• 86.22—Debridement
• DRG 813—Coagulation disorders
• DRG 870–871—Septicemia
• 54.51 and 54.50—Lysis of adhesions
• DRGs 981–989—For operating room procedures unrelated to the principal diagnosis

• DRG 551—Medical back problems
• DRG 313—Chest pain
• DRGs 377–379—Gastrointestinal hemorrhage with MCC, CC or without CC/MCC
• DRGs 640–641—Nutritional and miscellaneous metabolic disorders with MCC or without MCC (e.g. dehydration)
• DRG 291–293—Heart failure and shock with MCC, with CC or without CC/MCC (e.g. congestive heart failure)
• DRG 689–690—Kidney and urinary tract infections with MCC or without MCC
• DRG 682–684—Renal failure with MCC, with CC or without CC/MCC
• DRG 811–812—Red blood cell disorders with MCC or without MCC
• DRG 286–287—Circulatory disorders except AMI, with cardiac catheterization with MCC or without MCC
• DRG 264—Other circulatory system operating room procedures
• DRG 190–192—Chronic obstructive pulmonary disease (COPD) with MCC, with CC or without CC/MCC
• DRG 166–168—Other respiratory system operating room.procedures with MCC, with CC or without CC/MCC (e.g. transbronchial lung biopsy)
• DRG 222–227—Cardiac defibrillator implantations with or without cardiac catheterization   

Editor’s note: This tip is excerpted from HCPro, Inc.’s new book, The HIM Director’s Guide to Recovery Audit Contractors, by Jean S. Clark, RHIA. For more information on the book, click here.