3 rd Annual Association of Clinical Documentation Improvement Specialists Conference

1. 3rd AnnualAssociation of Clinical Documentation Improvement Specialists Conference

2. CDI and the RAC: Lessons Learned from the Demonstration and an Update on the Permanent Program Ann-Marie Carducci, RN, CCS, CPC, CPHQ, CPUR Director, Utilization Management Montefiore Medical Center

3. Goals • To discuss the preparation required for the RAC to optimize your organization’s results • To discuss the process to prevent recoupments • To recommend the membership necessary for a RAC team and each member’s roles • To review the Medicare appeals process

4. Montefiore Medical Center (MMC) • Overview • Nonprofit healthcare system with three acute care hospitals • ~1500 licensed beds • >93,000 discharges annually • 20% Medicare discharges

5. MMC’s RAC Demonstration experience • Part A: • Connolly Consulting • Requested 779 medical records • 127 admission denials • 202 DRG denials • 5 technical denials

6. RAC Demonstration experience CHALLENGE! • Financial risk to the organization • Total denial $$ at risk—$6.1M • Average DRG denial—$17k • Average admission denial—$21k • Average technical denial—$37k

7. RAC attack • RAC team • Identify the correct person as yourRAC liaison • Include finance, HIM, UM/CM, documentation improvement, billing compliance, data analysis, revenue cycle, medical director, appeals staff • Reporting structure to senior management • Administrative support

8. RAC team • Key responsibilities of team membership: • RAC liaison—central contact • Monthly and ad hoc meeting agendas, including medical record request trends, number and types of denials, oversee electronic tracking system, report on appeals status • Highlight improvement areas • Collaborate with hospital associations • Train administrative support on tracking system and report retrieval

9. RAC team • Key responsibilities of team membership: • Finance & revenue cycle • Confirm $$ on RAC letters • Review $$ reports of RAC denials • Decide whether recoupment should be paid up front (you can still appeal!) • Revise organizational budgets as indicated

10. RAC team • Key responsibilities of team membership: • HIM • Submission of “additional documentation requests” • Possibly preview records before submission to determine whether they’re RAC-proofed • Identify coding and provider educational opportunities • DRG appeals

11. RAC team • Key responsibilities of team membership: • Documentation improvement • Oversee the concurrent CDI process • Collaborate with UM/CM to identify non-medically necessary cases • Collaborate with HIM in RAC-proofing medical record documentation • Identify provider educational opportunities • Conduct in-services

12. RAC team • Key responsibilities of team membership: • Billing compliance • “Keeper of the rules” regarding coding and medical necessity • Calm finance down when monies have to be given back!

13. RAC team • Key responsibilities: • Data analysis and reporting • Data guru! • Slice and dice the data to respond to the numerous requests for “Can we look at the data from this perspective?” • Analyze closed RAC issues to identify whether an action plan is indicated

14. RAC team • Overall responsibilities: • Determine when to do audits. Compliance must weigh in heavily on this as it may lead to a return of $$$. • Decide whether internal resources are sufficient to handle the RAC denials. • Determine whether to outsource any aspect of the process (e.g., submission of records or appeals).

15. How to best prepare • Audits—self-audit. • You may want to do a random audit of sample charts. Focus on sepsis, chest pain, and other short stays. • Always flag the admission order in the record. • PEPPER—respond to the data. • Review RAC Internet site regularly— familiarize yourself with RAC areas of focus. Involve your CDI team!

16. How to best prepare • Educate DI staff on medical necessity and institute a process for DI staff to refer potential non-medically necessary cases to the UR/CM associate • Provide an educational curriculum for DI management to DI staff on RAC processes and results • Address areas of opportunity with an action plan • Review your queries—concurrent and retrospective

17. How to best prepare • Educate providers re: inpatient admission criteria vs. observation criteria • Identify CCs and MCCs that impact DRGs, especially those DRGs highlighted by reports (e.g., PEPPER) and by your RAC’s approved issues • Require your providers to include a diagnosis for the indication of every medication they order

18. How to best prepare • Facilitate meetings between your ED physicians and your inpatient physicians to ensure that diagnosis and procedure documentation is continued throughout the record • Medical director buy-in to require DI in-service for newly credentialed providers • Role definitions and expectations for RAC team members

19. How to best prepare • Educate RNs to document skin assessments and staging of pressure ulcers • Educate providers on how to document excisional debridement, especially when it’s performed at the bedside (see template note)

20. How to best prepare • During the concurrent DI process, trigger follow-up for high-risk RAC areas • If possible, involve management follow-up on significant issues

21. Excisional debridement

22. How to best prepare

23. How to prevent recoupment • Ask for extensions when necessary • Collaboration between DI and HIM • Opportunity for DI to in-service HIM on the clinical aspect of the chart, especially when there are new procedures or devices • Opportunity for HIM to educate DI on coding changes

24. How to prevent recoupment • Two pre-appeal opportunities: 1. Discussion phase: Contact the RAC on day 1-40 after receiving a RAC demand/results letter. Explain why you strongly feel the RAC’s rationale is erroneous. 2. Rebuttal phase: Submit written rebuttal within 15 days of receiving demand/results letter explaining why recoupment would be a financial hardship for your organization.

25. How to prevent recoupment • At the 1st and 2nd levels of the appeals process, you can submit your appeals early (day 30, 1st level, day 60, 2nd level) and it will offset recoupment of $$$ • Discuss with finance—interest will accrue from day 30 after demand/results letter if the denial is upheld

26. The appeals process • Be cognizant of deadlines for each appeal level • Be prepared—it’s a very lengthy process • Know when to involve the provider

27. The appeals process

28. The appeals process • Level 1—Redetermination • 120 days from the date of the demand letter • Appeal to the FI, carrier, or MAC, which has 60 days to respond • Write a letter to support codes and medical necessity (include reference to the “intent”) • Send with evidence (coding guidelines, article) and form CMS 20027

29. The appeals process • Level 2—Reconsideration • 180 days from the date of the Level 1 response • Appeal to the Qualified Independent Contractor (QIC), which has 60 days to respond • Further enhance the 1st level appeal letter to support codes and medical necessity (include reference to the “intent”) • Send with evidence (coding guidelines, article, letter from your physician) and form CMS 20033

30. The appeals process • Level 3—Administrative Law Judge (ALJ) hearing • File within 60 days from the date of the Level 2 response • 90 days to schedule the hearing • Must involve at least $120 claim • Must notify the QIC that you’ve requested an ALJ hearing

31. The appeals process • ALJ continued: • Mode of hearing varies: letter, in-person hearing, telephonic hearing, video teleconference • 60 days to issue a determination on the case • In your testimony, include the fact that it’s not clear whether a physician made the denial decision

32. The appeals process • ALJ continued: • Definitely involve the provider at this level. The provider can explain his or her rationale and the risks and benefits that he or she weighed prior to a decision. • Can word-smith around “If it’s not documented, it’s not done.” • Opportunity to explain to the judge what’s written in that terrible handwriting!

33. Success! • MMC: • 100% success at the ALJ level • Recommend writing a further enhanced letter when requesting a hearing (e.g., debridement) • Sometimes the letter alone will lead to a reversal!

34. Success! • Suggested format for live testimony: • Try to control the hearing • Prepare your testimony—reiterate what went on clinically with the patient and then directly refute key points from the Level 1 and 2 responses • Involve the provider and prep him or her beforehand!

35. The appeals process • Level 4—Medicare Appeals Council • File within 60 days from the date of the Level 3 response • No hearing (de novo review) • 90 days for Council to issue a determination • No monetary limit

36. The appeals process • Level 5—Final appeal • Judicial review in U. S. District Court • File within 60 days from the date of the Level 4 response • Must have at least $1,180 or more in controversy

37. The appeals process • Determine whether to submit 1st level appeal by day 30 after receiving the recoupment letter. This will delay recoupment of $ until day 41. • Determine whether to submit 2nd level appeal by day 60. This will further delay recoupment of $ until day 75. • BUT, interest will still accrue if the denial is upheld.

38. Our experience • For multihospital systems, check that the FI, carrier, or MAC has the correct address for outcome letters. • At the QIC level, we discovered a “screening” level. If a case failed screening, the denial was upheld (e.g., “no order to admit the patient”). • Letters of Agreement with consultants as backup resources.

39. Our experience • Coding Clinic, 1991, 3rd quarter—“unless a physician documents in the medical record that an excisional debridement was performed [with cutting away of tissues with a sharp instrument], debridement of the skin should be coded as debridement, 86.26.”

40. Success! • Excerpt from ALJ decision: • “The appellant included a ‘Debridement Physician Query’ signed by Dr.__. …In the query, Dr. __ indicated that the Beneficiary underwent a sharp, excisional debridement of necrotic tissue of an ulceration of her heel, using a scalpel and scissors. …The undersigned is CONVINCED … that the Beneficiary did in fact receive a sharp, excisional debridement …”

41. Our experience • MS-DRG 870—Septicemia with Mechanical Ventilation 96+ hours • MS-DRG 871—Septicemia without Mechanical Ventilation 96+ hours with MCC • MS-DRG 872—Septicemia without Mechanical Ventilation 96+ hours with MCC

42. Our experience • Speak with your infectious disease experts to define sepsis • Arm the DI staff with “expert” letters to support their queries • If sepsis is due to a vascular catheter, code 999.31 first, followed by the sepsis code

43. Our experience • Query to clarify the term “urosepsis” • Sepsis may be coded in the absence of positive blood cultures when there is clinical evidence of sepsis

44. Montefiore’s appeal outcomes Admission denials • Reversed 54% • Upheld 5% • Concede/rebill 41% Coding denials • Reversed 34% • Upheld 25% • Concede 37% • Modified 4%

45. Our experience • Must honor our VP, finance and his mantra of “All Roads Lead to Documentation!”Why does documentation matter? Medical Necessity Documentation Documentation Improvement Efforts

46. Update on the permanent program • Connolly and HDI requesting records for MS-DRGs 945 and 946 for acute inpatient rehab—not an approved issue! • RAC correspondence sent to incorrect hospital address • More than one ADR within 45 days! • RACs cannot review a record for a DRG issue and medical necessity unless it’s counted twice!

47. Update on the permanent program • We’ve heard from a number of hospitals that they’re seeing money recouped either before receiving the demand/results letter or a day or so after receiving the letter! • Challenge codes (e.g., a CPT code was challenged by a RAC claiming a biopsy was percutaneous when it was performed via a bronchoscopy!)

48. Update on the permanent program • Underpayments have been identified by some RACs. Treat these the same from a compliance perspective. • Patient Protection and Affordable Care Act of March 23, 2010, calls for RAC review of Medicaid claims by the end of 2010!!! Different rules may apply!

49. The appeals process

50. The appeals process