Health Information Management

Medical necessity audits: Involve coders in your RAC defense strategy

HIM Connection, November 16, 2010

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Hospitals have waited with bated breath for RAC medical necessity audits to begin. Now that the audits are well under way, the focus has shifted from anticipatory anxiety to best-practice defense strategies that experts say should involve a team of clinical individuals as well as coders.

All four RACs have now posted medical necessity issues for review on their websites. However, much remains to be seen in terms of how these audits will actually affect hospitals. 
 
RACs may find it very difficult to recoup money based on medical necessity simply because of the work it will take to prove a hospital stay doesn’t meet admission criteria, says Barbara Aubry, RN, CPC, CHCQM, FAIHCQ, regulatory analyst for 3M Health Information Systems in Wallingford, CT. The fact that CMS doesn’t dictate specific criteria for RACs to use when auditing admissions only complicates matters for all parties involved, Aubry says. 

Note: To read more, visit the HCPro website. Subscribers to Briefings on Coding Compliance Strategies have access to this article in the November issue of their newsletters.



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