Association-of-Clinical-Documentation-Improvement-.ppt
3rd AnnualAssociation of Clinical Documentation Improvement Specialists ConferenceAnn-Marie Carducci,RN,CCS,CPC,CPHQ,CPURDirector,Utilization ManagementMontefiore Medical CenterCDI and the RAC:Lessons Learned from the Demonstration and an Update on the Permanent ProgramGoals To discuss the preparation required for the RAC to optimize your organizations resultsTo discuss the process to prevent recoupments To recommend the membership necessary for a RAC team and each members rolesTo review the Medicare appeals processMontefiore Medical Center(MMC)OverviewNonprofit healthcare system with three acute care hospitals1500 licensed beds93,000 discharges annually20%Medicare dischargesRAC Demonstration experience CHALLENGE!Financial risk to the organizationTotal denial$at risk$6.1MAverage DRG denial$17kAverage admission denial$21kAverage technical denial$37kRAC attackRAC teamIdentify the correct person as yourRAC liaisonInclude finance,HIM,UM/CM,documentation improvement,billing compliance,data analysis,revenue cycle,medical director,appeals staffReporting structure to senior managementAdministrative supportRAC teamKey responsibilities of team membership:RAC liaisoncentral contactMonthly 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 areasCollaborate with hospital associationsTrain administrative support on tracking system and report retrieval RAC teamKey responsibilities of team membership:HIMSubmission of“additional documentation requests”Possibly preview records before submission to determine whether theyre RAC-proofedIdentify coding and provider educational opportunitiesDRG appealsRAC teamKey responsibilities of team membership:Documentation improvementOversee the concurrent CDI process Collaborate with UM/CM to identify non-medically necessary cases Collaborate with HIM in RAC-proofing medical record documentationIdentify provider educational opportunitiesConduct in-servicesRAC teamKey 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 How to best prepareAuditsself-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.PEPPERrespond to the data.Review RAC Internet site regularly familiarize yourself with RAC areas of focus.Involve your CDI team!How to best prepareEducate 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 resultsAddress areas of opportunity with an action plan Review your queriesconcurrent and retrospectiveHow to best prepareFacilitate 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 How to best prepareEducate RNs to document skin assessments and staging of pressure ulcersEducate providers on how to document excisional debridement,especially when its performed at the bedside(see template note)How to best prepareDuring the concurrent DI process,trigger follow-up for high-risk RAC areasIf possible,involve management follow-up on significant issues Excisional debridementHow to best prepareHow to prevent recoupmentTwo 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 RACs 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.How to prevent recoupmentAt 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 financeinterest will accrue from day 30 after demand/results letter if the denial is upheldThe appeals processBe cognizant of deadlines for each appeal levelBe preparedits a very lengthy processKnow when to involve the providerThe appeals processLevel 1Redetermination 120 days from the date of the demand letterAppeal to the FI,carrier,or MAC,which has 60 days to respondWrite a letter to support codes and medical necessity(include reference to the“intent”)Send with evidence(coding guidelines,article)and form CMS 20027The appeals processLevel 2Reconsideration180 days from the date of the Level 1 responseAppeal to the Qualified Independent Contractor(QIC),which has 60 days to respondFurther 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 The appeals processALJ continued:Mode of hearing varies:letter,in-person hearing,telephonic hearing,video teleconference60 days to issue a determination on the caseIn your testimony,include the fact that its not clear whether a physician made the denial decision The appeals processALJ 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 its not documented,its not done.”Opportunity to explain to the judge whats written in that terrible handwriting!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!Success!Suggested format for live testimony:Try to control the hearingPrepare your testimonyreiterate 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!The appeals processLevel 4Medicare Appeals Council 60 days from the date of the Level 3 responseNo hearing(de novo review)90 days for Council to issue a determinationNo monetary limitThe appeals processLevel 5Final appealJudicial review in U.S.District Court 60 days from the date of the Level 4 responseMust have at least$1,180 or more in controversyThe appeals processDetermine whether to submit 1st level appeal by day 30 after receiving the recoupment letter.This will delay recoupment of$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.Our experienceFor 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.Our experienceCoding 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.”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”Our experienceMS-DRG 870Septicemia with Mechanical Ventilation 96+hours MS-DRG 871Septicemia without Mechanical Ventilation 96+hours with MCCMS-DRG 872Septicemia without Mechanical Ventilation 96+hours with MCCOur experienceSpeak 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 codeOur experienceQuery to clarify the term“urosepsis”Sepsis may be coded in the absence of positive blood cultures when there is clinical evidence of sepsis Montefiores appeal outcomesAdmission denialsReversed 54%Upheld5%Concede/rebill 41%Coding denialsReversed 34%Upheld25%Concede 37%Modified 4%Our experienceMust honor our VP,finance and his mantra of“All Roads Lead to Documentation!”Why does documentation matter?DocumentationMedical NecessityDocumentation Improvement EffortsUpdate on the permanent programConnolly and HDI requesting records for MS-DRGs 945 and 946 for acute inpatient rehabnot 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 its counted twice!Update on the permanent programWeve heard from a number of hospitals that theyre 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!)Update on the permanent programUnderpayments 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!The appeals processThe appeals process
