CDI’s Impact on the Recovery Audit Contractor

1. CDI’s Impact on the Recovery Audit Contractor Capitalizing Upon Our Strengths to Minimize Hospital Financial Exposure

2. Objectives • Highlight 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

3. Objectives • CollaborationRecognize 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

4. Objectives • Understandhow 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.

5. CMS Policy GuidanceProgram Integrity Manual Guidance • ReviewChapter 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

6. CMS Policy GuidanceProgram Integrity Manual Guidance • CMS 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.

7. For each case, the review staff will utilize the following when making a medical necessity determination • Admission criteria • Invasive procedure criteria • CMS coverage guidelines • Published CMS criteria • Other screen, criteria, and guidelines (practice guidelines that are well accepted in the medical community)

8. Factors that need to be considered when making the decision to admit • Physicians should use a 24-hr period as a bench mark • They 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

9. Which can be made only after the physician has considered a number of factors • Patients medical history • Current medical needs • Types of facilities available and the appropriateness of treatment in each setting

10. Other factors to consider • The severity of the signs and symptoms exhibited by the patient • The medical predictability of something adverse happening to the patient

11. What is the Purpose of Documentation • To showthat the service was medically necessary • To justify billing the service at the level billed • To demonstratethat the standard of care was met, if needed, to defend against an action for malpractice • To assist clinicians who follow in performing subsequent care

12. Documentation Impacts • Medical necessity • Coding applications • Data integrity • Quality Concerns • Patient safety • Continuity of care • Appropriate reimbursement • Physicians case mix index and E/M

13. Case Study 1 • 86 yr old male • UTI • Admitted 4 day LOS • Insurance wants to change from Inpatient to Observation

14. Case study 2 • Presents 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

15. Coding Rules • If 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.

16. More Coding Rules • Pathology, 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.

17. Poll of WI ACDIS Members • Thanks to all that responded

18. Does your facility have somekind of RAC team? • I believe so • Yes • Yes • Yes, we have a RAC team at each site as well as a RAC Steering committee for our System

19. If yes do any CDIS serve a role on this team • No • No • Yes • CDIS are members of most teams. CDI and coding partner to write any DRG letters with clinical focus.

20. Top 3 reasons for denials (from survey) • This has not been shared with the CDIS • 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 • CDI denials: AKI/ARF, alternative principal diagnosis, ABLA,, rhabdovs ARF. - Coding denials: Sepsis vs Pneumonia

21. What process do you have for denials • Not sure as formal process has not been shared with CDIS, but I believe the Coding Supervisor has a role in this. • Yes we have a process. • We have a central RAC office for communications using RAC tracking software.

22. Does CDIS have a role in this process • No • No • Yes • Yes

23. Process for when CDIS and coders disagree. • CDIS emails form with information regarding case to Coding Supervisor who reviews case and responds to CDIS. • We no longer compare. • Review to see how we came up with DRG if needed then go to head of coding.

24. Process for when CDIS and coders disagree 4. Collaboration and compromise

25. Any Case to share • If 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

26. Discussion • Would 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?

27. Reason for Denials • The 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

28. Reasons for Denials • The 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

29. Reason for Denials • The 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 chart • Assessments identifying a medical condition requiring interventions • Barriers to discharge

30. Reason for Denial • Interdiscipliary team members did not chart • Assessments identifying a medical condition requiring interventions • Barriers to discharge • Actual interventions used to address assessment abnormalities • Evaluation of services rendered to the beneficiary indicating the patient’s response to services

31. What Should be Documented • The patients condition • The patients need for services and prior failed interventions • The plan of care to address the patient’s specific health care needs • The results of lab test, x-ray and other DI results ordered by the physician. • The risk factors complicating the patient’s health condition • The patient’s response to surgery, procedures, medical interventions and therapies • Progress made in the patient’s condition and POC • Any setbacks

32. What Should be Documented • Any 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

33. Documentation Tips for Physicians • Review 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.

34. Document Tips for Physicians • When a patient is admitted as an inpatient, clearly indicate the diagnosis or major concern that would need to be managed in the inpatient setting.

35. Documentation Tips for Physicians • The 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

36. Documentation Tips for Inpatient Staff • Clearly document the patient’s presentation and clinical assessments • Provide 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

37. Documentation Tips for Inpatient Staff • Clearly 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

38. Documentation Tips for Medical Records • Ensure 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

39. Thank You • Questions • Discussion