Are You Ready for the RACs 100208 [Final] Phys Practice Institute …€¦ · ·...

888-580-8373 | www.hcca-info.org

Health Care Compliance Association6500 Barrie Road, Suite 250, Minneapolis, MN 55435888-580-8373 | www.hcca-info.org

Compliance & Clinical Documentation

Improvement:

Are You Ready for the RACs ?

Betty B. Bibbins, MD, CHC, C-CDI, CPEHR, CPHITPresident & Chief Medical Officer

DocuComp LLC

October 2, 2008


Objectives

• Understand the role of the Recovery Audit Contractor (RAC).

•Demonstrate the importance of CDI Specialists.

•Demonstrate examples of appropriate documentation.

•Example of responding to and appealing denials regarding quality of care issues.


Recovery Audit Contractors (RAC)

• RAC Authorized in Congress in 2003.

• RAC demonstration programs begun in Florida, New York, and California in 2005.


RACs

Centers for Medicare & Medicaid Services (CMS) contracted with RACs to:

- Detect past Medicare improper payments (including both underpayments and overpayments); and

- Correct past Medicare improper payments (i.e., repay money to a provider who was underpaid or collect money from a provider who was overpaid).

- Paid on a contingency fee (20-25%) for identifying and correcting improper payments


RAC Accomplishment FY 2007

RAC Identified and Corrected $371 million dollars of Medicare Improper Payment during FY 2007:

- Greater than 96% of these improper payments were overpayments collected from providers.

- Remaining 4% of the improper payments identified were underpayments (Not surprising).


Just Announced RAC Pilot Program Three Year Results

RAC Contractors returned $693.6 million in improper Medicare payments to the Medicare Trust Fund between March 2005-2008.

Of the overpayments:

- 85% were collected from inpatient hospital providers.

- 6% were from inpatient rehab providers.

-4% were from outpatient hospital providers.


RAC Accomplishment FY 2007

32% of improper payments -

Medically Unnecessary Service or Setting


Design of the RAC Program

Retroactive back 3 years from date of claim

or

Oct. 1, 2007.


Defining Medically Unnecessary Services

RAC do not use any hard and fast rules and criteria in determining whether a hospitalization is appropriate for inpatient versus observation.

The RAC criteria for determining medical necessity is like Jell-O, loose and a moving target.


Reference

Center for Medicare & Medicaid Services

RAC Status DocumentFY 2007

“Status Report on the Use of Recovery Audit Contractors (RACs)

In the Medicare Program”

http://www.cms.hhs.gov/RAC/Downloads/2007%20RAC%20Status%20Document%20vs1.pdf


Insufficient Documentation

Insufficient documentation

means that the provider did not include pertinent patient facts (e.g.,

the patient’s overall condition, diagnosis, and extent of services performed) in the medical record

documentation submitted.


Physician Clinical Decision Making Is Pivotal

• The determination of an inpatient or outpatient status for any given patient is specifically

reserved to the admitting physician, although the physician has Medicare guidelines that he/she is

expected to follow.

• The decision must be based on the physician’s expectation of the care that the patient will

require.


Justification for Admission

• Justification for admission is based on the information available at the time of admission, including:

• Abnormal lab and radiology diagnostic tests,

• Patient’s clinical signs & symptoms,

• Clinical suspicions, and

• Risk of morbidity and mortality.

• Subsequent clinical information may support a physician’s “suspicion” (clinical judgment) that the patient needed inpatient care.


Bottom Line

• Bottom Line ↔ Lack of complete and accurate diagnoses reporting on every daily progress note contributes to instances of “Insufficient

Documentation”.

• Examples include documentation:

• Proceed as planned.

• Doing Better.

• No new complaints.

• Stable, discharge in the morning.


Documentation Tips

Clinically significant but low SOI:

• Severe Hypoxia (S&S)

• Urosepsis

• Uncontrolled NIDDM

• Severe COPD on continuous O2

• Community Acquired Pneumonia and dysphasia, s/p CVA.

• ↑ Serum Na of 145 mEq/L

Greater SOI Captured:

• Early or mild Acute Resp. Failure

• UTI with Sepsis

• Type 2 DM with Hyperosmolarity,uncontrolled

• Chronic Respiratory Failure

• Possible Aspiration Pneumonia –Community Acquired

•Hypernatremia


How can Hospitals help Physicians

to appropriately

document

the Severity-of-Illness

to justify the

Consumption-of-Resources???


Clinical Documentation Improvement Programs

• Allowing the physician to maintain focus on the practice of medicine.

• Bridging the gap between “Clinical and Economic Language” ∪∪∪∪ ICD-9 codes.

• Helping the physician document & report the practice of medicine.

• Assisting the physician in maintaining compliance with DRG and E & M documentation requirements.

• Communicates the physician’s medical decision making in explicit medical record documentation.


CDI Personnel do not tell physicians how to practice

Medicine….Just provide support on how to appropriately

document their practice of medicine.


How Does This Work?

Clinical Documentation Improvement Specialists (hospital employees) review inpatient medical records concurrently:

• Seek to clarify conditions being managed but not documented.

• Transform medical decision making from implicit to explicit documentation.

• Provide documentation tips to permit capturing and reporting of all pertinent diagnoses.


Key Points of a CDI Program

• Unobtrusive to the practice of medicine.

• Serves as a resource to the practice of medicine.

• Serves as a conduit for “translation” and communication of quality care provided.

• Maintains compliance standards day-to-day.


Revenue Cycle Initiatives

Appropriate Documentation

Accurate ICD-9 Coding and DRG Assignment

Accurate, Optimal, & Compliance Reimbursement


www.Hospital Compare.gov • Provides a tool for Medicare to determine

how well the hospitals care for their adult patients with certain conditions and procedures.

• The following conditions are available on Hospital Compare.

• Heart Attack

• Diabetes in Adults

• Chest Pain

• Heart Failure

• Chronic Lung Disease

• Pneumonia


Three Outcomes Tracked & Trended by Medicare

• Thirty day mortality of Medicare patients and In-House Mortality:

– Pneumonia

– Congestive Heart Failure

– Myocardial Infarction

• All pneumonias, heart failures, and myocardial infarctions are not created equal.

• Documentation truly matters.


Focal Point

•• Medical Record DocumentationMedical Record Documentation→→→→

– Emergency Room Physician Notes

– Progress Notes

– History & Physical

– Consultant Notes

– Discharge Summary

***New in 2009: Dietitian and Wound Care documentation


• Documented Dx = ICD-9 codes = Raw Data

• Raw data analyzed and processed.

• Final Product ↔↔↔↔ Measures of: ◦Outcomes, ◦Quality scores, ◦Efficiency, ◦Cost effectiveness in medicine.


Outcome Measures

• Outcome measures are risk adjusted:

– Providers should not be financially penalized for the poorer outcomes of high-risk patients.

• Physicians CAN influence the reporting risk of morbidity and mortality through complete and accurate medical record documentation.


Data is only as good the quality of clinical documentation!

Physician Documentation is the Key!


Clinical Documentation

• Documentation is vital to compliance.

• Clear and accurate documentation ≠≠≠≠

More Documentation.

• Clear and accurate documentation = More Effective Documentation


The most effective way to improve accuracy of quality measures:

• Verify medical necessity.

• Reduce medico-legal risk.

• Justify patient disposition and outcome.

• Enhance the physician’s ability to justify the medical decision making component of E&M services.

•Support the hospital’s ability to obtain appropriate revenue for services rendered and resources utilized.


Beyond Reimbursement

Reimbursement

Measure Efficiency

& Effectiveness

Quality Outcomes


Sample Healthgrades.com 2007 Profile Based on 2003 – 2005 MedPar Data

ABC DEF GHI JKL MNO

Med Ctr Med Ctr Comm Hosp Med Center Med Ctr

Heart Failure

Hosp plus 1 month

Comm Acq Pneumonia

Hosp plus 1 month

Aspiration Pneumonia

Hosp plus 1 month

COPD

Hosp plus 1 month

Sepsis

Hosp plus 1 month

Acute MI

Hosp plus 1 month

Hip Fracture

Partial Hip Replacement

Cholecystectomy

Prostatectomy


WHAT CAN WE DO?


Document Appropriately:

Cost Effective, Quality Care =

“The Right Care →At The Right Place →

At The Right Time”.


1. READ THE CONTENT OF WHAT

CONCERN IS BEING STATED AND/OR REQUESTED.

2. DETERMINE WHAT INFORMATION

NEEDS TO BE CLARIFIED OR RESPONDED TO.

3rd Party Denials and Quality of Care Issues

34


1. REVIEW CLINICAL CONTENT FOR APPROPRIATE CAPTURE OF SEVERITY OF

ILLNESS.

2. QUERY PHYSICIAN.

3. RESPOND ONLY TO WHAT IS QUESTIONED BY THE 3RD PARTY.

4. RESPOND, RESPOND, RESPOND.

ACT - RESPOND

35


Thank You

Contact Information:Betty B. Bibbins, MD, CHC, C-CDI, CPEHR,CPHIT

President & Chief Medical OfficerEmail: [email protected]

Website: www.DocuCompLLC.comPhone: (740) 968-0427

Are You Ready for the RACs 100208 [Final] Phys Practice Institute …€¦ · ·...

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