Examine RAC audit of acute respiratory failure

Association of Clinical Documentation Improvement Specialists, November 1, 2011

The most recent issue of the Medicare Quarterly Provider Compliance Newsletter (volume 1, issue 4), which CMS posted in July, called attention to several recovery audit contractor (RAC) findings. For example, RACs evaluated a case assigned to MS-DRG 189 (respiratory failure), specifically the principal diagnosis and any secondary diagnoses affecting or potentially affecting the DRG, to determine that these diagnoses were actually present, correctly sequenced, and clinically validated, according to the newsletter.

CMS provided the following example:
An 81-year-old female was admitted with complaints of dry cough for a couple of weeks. The patient was admitted through the emergency department (ED) and was assessed for wheezing and coughing. History and physical (H&P) impression is acute respiratory failure secondary to exacerbation of chronic obstructive pulmonary disease (COPD). Progress notes through the stay also document the diagnosis of acute respiratory failure secondary to exacerbation of COPD. Final diagnosis on the discharge summary is acute respiratory failure secondary to COPD exacerbation. Additional documentation sheet supplied in the record list the patient's diagnoses as: Principal diagnosis: COPD exacerbation; Other diagnoses: high blood pressure, coronary artery disease (CAD), congestive heart failure (CHF), diabetes mellitus (DM), Parkinson's, and rheumatoid arthritis.
Even though the physician documented acute respiratory failure three times (i.e., in the H&P, progress notes, and discharge summary), the auditor deleted acute respiratory failure (code 518.81), substituting code 799.02 (hypoxemia), and changed the principal diagnosis to COPD exacerbation because the RAC reviewer determined that the clinical evidence in the medical record did not support respiratory failure as a valid diagnosis as to be coded and thus could not be sequenced as the principal diagnosis.
Therefore, the MS-DRG changed from 189 (pulmonary edema and respiratory failure) with a current relative weight of 1.2809 to 192 (chronic obstructive pulmonary disease without CC/MCC) with a current relative weight of 0.7220.
“So they took out a code assigned for a condition explicitly documented by a licensed physician who had face-to-face contact with the patient because they felt the condition was not present. That is the big take-home message,” says James S. Kennedy, MD, CCS, managing director at FTI Consulting in Atlanta.
“Even if a doctor documents the condition in the H&P, progress notes, and discharge summary … Medicare appears to be allowing RACs and their physicians to practice medicine in the assignment of codes.” (For more on this topic, access MLN Matters article MM6954, which addresses clinical review judgment.)
This example underscores the importance of examining the documentation and coding process at your facility to determine whether your staff has the proper mindset about the clinical congruence of the codes that they assign, says Kennedy, who explains that coders may have to adjust their approach. They need to be diligent about ensuring that the documented condition has clinical indicators to support the presence of that condition.
“Even if the doc calls it a duck, it waddles, and it quacks, the RAC or clinical reviewers can have different definitions for that duck,” he says. “A good lawyer always knows the law, but the best lawyer always knows the judge and the jury.”
For cases in which you decide to appeal the RACs coding adjustment, make sure that your physicians involved on the care for that patient are on board and involved in writing the appeals letter, says Angela Worden, RN, also a managing director at FTI Consulting in Atlanta along with Kennedy. Physicians should detail not only the condition that they diagnosed the patient as having but also the clinical evidence for why they assigned that diagnosis.

Editor's Note: This article originally appeared on JustCoding.com.

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