Health Information Management

Involve coders in your RAC defense strategy

HIM-HIPAA Insider, November 23, 2010

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Now that RAC medical necessity 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. One thing coders can do is assist in data mining for the following RAC targets.

Coders can help mine data for a variety of RAC targets, including the following:
  • Short-stay, uncomplicated admissions. RACs are homing in on these admissions because they are the ones most likely to be medically unnecessary, says Deborah K. Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, LLC, in Shawnee, OK. Also consider focusing on short length of stay and total low-charge cases assigned to high-weighted MS-DRGs (e.g., chronic obstructive pulmonary disease with an major complication or comorbidity (MCC)). This is because the MCC is not likely supported by documentation in the record, says Hale.
  • Noncardiac chest pain. Hospitals that struggle with admissions for noncardiac chest pain should ask these questions: Are the admissions truly cardiac in nature, and if so, why can’t physicians determine and document that? Why are patients admitted with noncardiac chest pain, particularly when those patients don’t have any CCs or MCCs? Finally, how can physicians provide better documentation? For example, if a physician documents “rule out myocardial infarction, patient responds to Advil, and cardiac enzymes are negative,” this may clue in a coder to the fact that it’s noncardiac pain, says says Barbara Aubry, RN, CPC, CHCQM, FAIHCQ, regulatory analyst for 3M Health Information Systems in Wallingford, CT. When coding concurrently, coders can flag the account for a case manager’s review, as the patient will likely not meet admission criteria.
  • Medical low back pain. Almost no admission criteria support inpatient admission for medical low back treatment, so hospitals should not have a high volume of related cases, says Aubry.
  • High-volume elective surgical procedures. Pay close attention to MS-DRGs that are driven primarily by assignment of these procedures, says Hale. Look for admissions that occur for these surgical procedures (e.g., joint replacement, coronary stents, and implantable defibrillators) when the documentation doesn’t support medical necessity for the procedure performed. Coders should work together with case managers to determine in advance which cases won’t meet medical necessity criteria, says Aubry. The hospital can also pre-certify these types of cases to help determine accurate patient status assignment, she adds.
Editor’s note: For additional tips for involving coders in your RAC defense, see the November issue of Briefings on Coding Compliance Strategies.

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