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Capitalizing Upon Our Strengths to Minimize Hospital Financial Exposure
CDI’s Impact on the Recovery Audit Contractor
ObjectivesHighlight and describe
the effects of clinical and coding interpretation upon risk of pre and post payment chart audits and their financial implications
Outline the merits and supporting role
of “quality” clinical documentation on financial exposure reduction inherent to internal and external medical record audits common to third party payer provisions
ObjectivesCollaboration
Recognize how CDI specialist can work in collaboration with case management, utilization review and revenue cycle denial teams in a prospective manner as part of a CQI initiative to learn from “mistakes” and reduce denials
ObjectivesUnderstand
how the CDI Specialist can play and active role in the RAC process, building upon the fundamental premise of CDI beyond reimbursement that incorporates a holistic approach to effective clinical documentation improvement.
CMS Policy GuidanceProgram Integrity Manual GuidanceReview
Chapter 6, Section 6.5.1, of the Medicare Program Integrity Manual requires that contractor review staff use a screening tool as part of their medical review process for inpatient hospital claims.CMS does not require that the contractor use
specific criteria nor endorse any particular brand of screening guidelines.
CMS contractors are not required to pay a claim even if screening criteria indicate inpatient admission is appropriate
CMS Policy GuidanceProgram Integrity Manual GuidanceCMS Contractors are not required to
automatically deny a claim that does not meet the admission guidelines of a screening tool
In all cases, in addition to screening instruments, the reviewer shall apply his/her own clinical judgment to make a medical review determination based on the documentation in the medical record.
For each case, the review staff will utilize the following when making a medical necessity determination
Admission criteriaInvasive procedure criteriaCMS coverage guidelinesPublished CMS criteriaOther screen, criteria, and guidelines
(practice guidelines that are well accepted in the medical community)
Factors that need to be considered when making the decision to admitPhysicians should use a 24-hr period as a
bench markThey should order admission for patients
who are expected to need hospital care for 24 hours or more
However the decision to admit a patient is a complex medical judgment
Which can be made only after the physician has considered a number of factorsPatients medical historyCurrent medical needsTypes of facilities available and the
appropriateness of treatment in each setting
Other factors to considerThe severity of the signs and symptoms
exhibited by the patient
The medical predictability of something adverse happening to the patient
What is the Purpose of DocumentationTo show that the service was medically
necessaryTo justify billing the service at the level
billedTo demonstrate that the standard of care
was met, if needed, to defend against an action for malpractice
To assist clinicians who follow in performing subsequent care
Documentation ImpactsMedical necessityCoding applicationsData integrityQuality ConcernsPatient safetyContinuity of care Appropriate reimbursementPhysicians case mix index and E/M
Case Study 186 yr old maleUTIAdmitted 4 day LOS Insurance wants to change from Inpatient
to Observation
Case study 2Presents with chest pain as obs status ptca
procedure changed to inpt status Medical PDX coded as CAD w/ ptca /stent
and AMI as MCC outside auditor wanted the AMI as the PDX with no MCC
Coding RulesIf it’s not absolutely clearly documented –
we cannot code it.Example
Hemorrhage after surgery – Hg 5 – Two units PRBC
Cannot accurately code hemorrhage.Cannot code blood loss anemia.Cannot code anemia.
More Coding RulesPathology, radiology, or laboratory reports
present in the chart, but not reviewed and interpreted, essentially do not exist for coding purposes.
We cannot “interpret” the results – only the attending physician can.
Do not use symbols. These are not visualized by the coders.
Does your facility have somekind of RAC team?1. I believe so2. Yes3. Yes4. Yes, we have a RAC team at each site as
well as a RAC Steering committee for our System
If yes do any CDIS serve a role on this team1. No2. No3. Yes4. CDIS are members of most teams. CDI
and coding partner to write any DRG letters with clinical focus.
Top 3 reasons for denials (from survey)1. This has not been shared with the CDIS2. Medical Necessity, Excisional
Debridement, Major small & large bowel procedures, Cardiac Value & other Major Cardiothoracic Procedure, Disease and disorders of the Respiratory system, Intracranial Hemorrhage or Cerebral Infraction
3. CDI denials: AKI/ARF, alternative principal diagnosis, ABLA,, rhabdo vs ARF. - Coding denials: Sepsis vs Pneumonia
What process do you have for denials1. Not sure as formal process has not been
shared with CDIS, but I believe the Coding Supervisor has a role in this.
2. Yes we have a process.3. We have a central RAC office for
communications using RAC tracking software.
Process for when CDIS and coders disagree.1. CDIS emails form with information
regarding case to Coding Supervisor who reviews case and responds to CDIS.
2. We no longer compare.3. Review to see how we came up with DRG
if needed then go to head of coding.
Any Case to shareIf not documented in discharge summary
RAC is saying it is conflicting information. Renal failure vs Renal insufficiency
Clinical documentation missing word acute – blood loss anemia
DiscussionWould it be more effective
for CDI to reinforce the concepts of documentation reflective of the reporting of physicians' clinical judgment, medical decision making and amount of work performed or to spend most of their time focused on capturing CC’s/MCC’s and PDXs without supporting documentation from physician in the record?
Reason for DenialsThe medical record was not received on
time.The claim was not submitted on the
appropriated bill type.The medical records did not substantiate
the medical necessity for the level of care billed
The documentation did not adequately support the services billed
Reasons for DenialsThe documentation did not show that the
billed services were rendered to the patient.
The physician ordered outpatient but an inpatient claim was filed
The physician orders and progress notes did not provide sufficient information for the purpose of treatment, medical or surgical interventions
Reason for DenialsThe patient’s condition, reason for
procedure, surgical intervention or need for an implantable device were not documented in the medical record
Interdiscipliary team members did not chartAssessments identifying a medical condition
requiring interventionsBarriers to discharge
Reason for DenialInterdiscipliary team members did not
chartAssessments identifying a medical condition
requiring interventionsBarriers to dischargeActual interventions used to address
assessment abnormalitiesEvaluation of services rendered to the
beneficiary indicating the patient’s response to services
What Should be DocumentedThe patients condition The patients need for services and prior failed
interventionsThe plan of care to address the patient’s specific
health care needsThe results of lab test, x-ray and other DI results
ordered by the physician.The risk factors complicating the patient’s health
conditionThe patient’s response to surgery, procedures,
medical interventions and therapiesProgress made in the patient’s condition and POCAny setbacks
What Should be DocumentedAny barriers to treatments, complications
that need to be addressed before other treatments can be initiated.
H&P information and risk factors influence physician treatment decisions that present risk that reduces the improvement of the patient’s condition
Documentation Tips for PhysiciansReview dictations to determine if the
information is correct.When ordering a change in the patients
status, clearly document the clinical reasons for the change.
Validate verbal and phone orders with a legible signature, credentials and date. Ensure physician cosigning signature is clear and legible.
Document Tips for PhysiciansWhen a patient is admitted as an inpatient,
clearly indicate the diagnosis or major concern that would need to be managed in the inpatient setting.
Documentation Tips for PhysiciansThe physician should document the
progression of the patient’s condition. Tell the story of what and why each services has been ordered. Also document the condition of the patient after ER treatment, if the patient is admitted
Documentation Tips for Inpatient StaffClearly document the patient’s
presentation and clinical assessmentsProvide room air saturations with vital signs
including on discharge.For patients with vomiting and diarrhea ,
document the number of episodes and the consistency of the stools and emesis. If none was observed document this also
Documentation Tips for Inpatient StaffClearly document IV fluids and IV medications.
Documentation of start times and stop times. Document rates and describe IV routes as PICC line, Central line, etc.
Avoid writing over other entries in the chart. Overlapping entries distorts the documentation and reduces legibility making it difficult to determine what was written
Ensure that the documentation supports the plan of care, interventions and treatments. Also document the patient’s response to the treatment
Documentation Tips for Medical RecordsEnsure all documentation in the ADR
( additional development request, denial, appeal)is provided for medical review
Ensure that the medical record is in order and provides a complete picture of what occurred on each day.
Ensure that all documentation is provided in a manner and size