Hospitals in demo project prepare for permanent RACs
Hospitals in demo project prepare for permanent RACs
Data analysis aimed at avoiding denials
After the Recovery Audit Contractor (RAC) demonstration project ended, participating hospitals began looking for ways to minimize their risk and resources when the permanent RACs are rolled out.
For instance, Sharp HealthCare, a seven-hospital system with headquarters in San Diego, completed a Six Sigma workout on lessons learned from the pilot to identify where the system's vulnerabilities were and to develop a proactive audit plan, says Kari Cornicelli, CFO at Sharp Grossmont, a 536-bed hospital in La Mesa, CA.
The committee identified all areas of risk, put them in priority, and developed a process around each one, and assigned responsibility. For instance, the hospital system analyzed the MS-DRGs that the Centers for Medicare & Medicaid Services (CMS) has identified as at risk, such as cardiac device implantation and respiratory failure, and is conducting regular chart reviews on them.
"We've always done coding audits, but we changed our corporate audit plan to focus on DRGs at risk for RAC denials. We are proactively auditing every hospital quarterly based on RAC vulnerability areas and are doing full-chart audits as well," Cornicelli says.
Safeguards in billing system
The health system put in safeguards within the billing system to avoid duplicative billing for areas that could be at risk, such as physical therapy or occupational therapy units or infusion services.
The health system also is taking a proactive approach to documentation to educate the staff on what needs to be done to avoid RAC denials.
For instance, the RAC team is analyzing its rates of complications and comorbidities (CC) and major complications and comorbidities (MCC) to determine if they are out of balance on what the national average is running and drilling down to make sure they are correct, she adds.
Sharp HealthCare already was prepared for the RACs because it launched a systemwide educational initiative when the new MS-DRG system was rolled out, adds Tony Guerra, CFO for Sharp Coronado.
"Since the RACs were focusing on documentation and we'd already provided education as it related to the MS-DRGs, we were well prepared," he says.
After the demonstration program, North Shore-Long Island Jewish Health System analyzed the demonstration project record requests to determine what the targets were likely to be in the permanent RAC process and developed task forces of experts in each area of risk, says Deborah Mallon, RN, MPA, CCS, assistant vice president, clinical documentation management,
For instance, there is a sepsis task force staffed by a multidisciplinary group of people who are experts on the subject and who can provide the information necessary to appeal any denials.
The health system has focused on clinical documentation improvement in some of the RAC target areas, such as debridement and defibrillator placement.
For instance, when patients are having pacemakers implanted, the case is reviewed for medical necessity by the clinical documentation specialist as well as the front-end people, Mallon says.
Focus on wound debridement
As a result of a focus on wound debridement, the health system has put a process in place to review excisional debridement cases to ensure that the documentation supports excisional debridement vs. nonexcisional debridement.
"Once we have completed our research defending the medical necessity and/or coding of a particular case, we save all those references, such as literature, screening criteria, and coding guidelines — whatever it takes to support our position. This way we can use the information for future appeals," says Bridgette Kreuder, RN, CCS, director of quality, coding, and appeals for North Shore-Long Island Jewish Health System.
When cases are identified that the team believes are appropriately coded but the key information might not be clearly evident in the medical record in terms of ICD-9 terminology, the health system confers with the physician who specializes in that area to draft a letter to add supplemental information supporting the original coding in the medical record.
Based on the RAC reviews, the health system also is working to ensure that the principal diagnosis is clearly and consistently documented throughout the stay and in the discharge summary, Kreuder adds.
"Without consistent documentation, coders cannot select the principal diagnosis," she adds.
For instance, a physician initially may write "rule out sepsis," then "treat for sepsis" and during the rest of the stay refers to the diagnosis as pneumonia.
"This is confusing to the coder and a red flag to the RACs," she adds.
St. Vincent's Health in Jacksonville, FL, part of Ascension Health, has a contract with an external physician adviser company, which reviews charts for compliance when there is a question about medical necessity.
Many of the denials that were appealed had already gone through the external physician company for review and the hospital system already had determination letters assigning the admission status, says Jamie Zachary, LSCW, director of care management for the two-hospital system.
"This makes responding to the RAC denials so much easier," she adds.
After the Recovery Audit Contractor (RAC) demonstration project ended, participating hospitals began looking for ways to minimize their risk and resources when the permanent RACs are rolled out.Subscribe Now for Access
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