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.

Poll of WI ACDIS Members Thanks to all that responded

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.

Does CDIS have a role in this process1. No2. No3. Yes4. Yes

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.

Process for when CDIS and coders disagree

4. Collaboration and compromise

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

Thank YouQuestionsDiscussion