Training Programs
Audits & Assessments
Regulatory MonitoringArchive for audit
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Case-mix index. Track this monthly and look for changes. What is your highest-volume DRG, primary diagnosis, and secondary diagnosis?
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Accurate and complete coding. Know the Uniform Hospital Discharge Data Set definition of principal diagnosis: “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
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Physician documentation. This is key to accurate code assignment. Have your clinical documentation improvement specialist determine where improvements are needed.
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Coding audits. Perform audits regularly to evaluate accuracy and potential over- or undercoding.
Healthcare providers in several states received their first RAC denials.
Connolly Healthcare, the Region C RAC for Florida, South Carolina and several other states, has been behind many of them.
One hospital in South Carolina reports having three claims denied. However, learning of those denials did not go smoothly. The hospital received a call in late October from Connolly regarding a denial letter the hospital never received. The RAC sent the original denial letter in early August, and although it was addressed to the hospital, it apparently had no specific contact person listed, and the hospital never received it. Read More→
If you’ve been audited by a RAC–for example, perhaps you’ve received a demand letter in the mail indicating a RAC has denied one of your claims–we want to hear from you.
The first three providers to share their stories will receive a free audio conference from HCPro. E-mail editor Andrea Kraynak (akraynak@hcpro.com) if you have a story to share.
As of September 18, all four RACs were conducting automated audits, according to an October 6 American Hospital Association (AHA) RAC program update. But only 16 of the 23 audits underway were on hospital outpatient claims, according to the AHA. (The others were therefore on physician and durable medical equipment claims.)
So unless your hospital is so very unlucky to have been selected as one of the first for an audit, chances are you still have time to make a few necessary tweaks and run a few tests on your RAC processes to help ensure you’re ready when RACs do begin auditing your facility.
By Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.
On September 11, CMS published Transmittal 302 that updated the Program Integrity Manual on Local Coverage Determination (LCD) exceptions. When specific authorized contractors conduct a complex medical review, they have the authority (in rare and unusual circumstances) to apply an exception to the “reasonable and necessary” requirements described in an LCD to approve or deny a claim. However, they cannot make exceptions to National Coverage Determinations (NCDs). In addition, and unless otherwise directed by CMS, RACs can only use the exceptions process to not deny a claim. This is a good time to review the difference between a national and a local coverage determination policy.
Click over to the MedicareMentor Blog to read more.
Connolly, the RAC for Region C, approved several issues for North Carolina providers on September 10.
The following issues have been approved for outpatient hospitals and physicians in North Carolina:
- Untimed codes
- Once in a lifetime procedures
- Pediatric codes exceeding age parameters
- J2505: Injection, Pegfilgrastim, 6 mg
Connolly may also audit Durable Medical Equipment (DME) providers in North Carolina for Wheelchair bundling and Urological bundling.
The Office of Inspector General (OIG) will be searching for relevant information prudent to your hospital’s audit. This information is called evidence. To support your audit begin to collect four types of evidence before the OIG visits:
- Physical Evidence: Paraphernalia obtained through direct inspection of property, events, and people. (e.g., maps, photographs, illustrations, written summaries of observations, charts)
- Documentary Evidence: Created evidence including: spreadsheets, accounting records, contracts, invoices, letters, performance reports, and surveys.
- Testimonial Evidence: Information received through bias-free interviews and inquiries from individuals involved in the particular audit.
- Analytical Evidence: Collect analytical evidence through the verification of amassed information, facts, and data. Laws, legal and non-legal opinions, hospital standards, and past and present operations should all be compared to your analytical findings.
This week’s tip was adapted from The Healthcare Auditor’s Handbook, for more information about the book or to order your copy click here.
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