Strategy: Expand your CDI horizons by examining medical necessity of inpatient stays
CDI Strategies, September 4, 2008
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CDI specialists can increase their value and professional standing at their hospital by taking a few minutes to examine physician orders relating to the medical necessity of observation vs. inpatient status, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, senior coding and chargemaster consultant with QHR in Brentwood, TN.
Krauss says Fiscal Intermediaries and Medicare Administrative Contractors plan to examine claims for medical necessity and coding accuracy pre-bill, instead of post-review. View p. 46 (p. 52 of the PDF) of The Medicare Recovery Audit Contractor (RAC) Program: An Evaluation of the Three-Year Demonstration report for evidence of this trend.
Payers often deny claims in which physicians classify patients for observation status but later admit them after a typical 23-hour observation period, he says. A main reason for denial is scant and inadequate physician documentation. “Nine times out of 10, there’s no documentation of a reason why the patient can’t go home,” Krauss says.
When they see a case that’s ripe for denial, CDI specialists should help attending physicians capture and report their medical decision-making, Krauss says. Impress upon them the need to document their thoughts as to why they admitted the patient, he adds. For example, it may be as simple as asking the physician to document the following: “In light of the borderline enzymes and EKG changes after 23 hours, I’m still concerned about an evolving MI. The patient has also had repeated bouts of chest pain and visits to the emergency room, a family history of early cardiovascular disease, and risk factors for MI including age over 70, smoking history, obesity, hypertension, hyperlipidemia, sedimentary lifestyle and noncompliance with medication. So I plan to admit the patient.” This level of documentation can also serve as the basis of an appeal letter in the event that a third-party payer denies the claim, says Krauss.
Krauss says that CDI specialists should broaden their horizons for review, even if it means adding some work to their day. It may pay off with added standing and perhaps increased value to their organization. “It’s not just about inpatients, it’s about observation cases that go to inpatient, or outpatient surgical cases that go to observation and become inpatients,” he says. “Documentation specialists should not be focusing just on inpatients, they should be focusing on areas under scrutiny by the RACs.”
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