Health Information Management

Tip: Pay attention to MACs, not just RACs

CDI Strategies, October 15, 2009

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With all the attention these days squarely on Recovery Audit Contractors (RAC), CDI specialists could be missing compliance initiatives of equal or greater importance issued by their local Medicare Administrative Contractor (MAC).
Case in point: NHIC Corp, A/B MAC for Jurisdiction 14, on September 24 released a document entitled “Medical Review of Inpatient PPS Claims—What did the DRG Validation Review Reveal?” The document summarizes the results of a DRG validation review of hospitals in the states of Wisconsin, Michigan, New York, and Connecticut. The DRGs included in the study were:
  • 061, 062, and 063: Stroke-related DRGs
  • 064, 065, and 066: Intracranial hemorrhage DRGs
  • 067 and 068: Non-specific CVA DRGs
  • 069: Transient ischemic attack (TIA)
The pilot project review included 396 cases from the four states. The overall error rate was 5.8%. Some specific sources of error included:
  • Untimely discharge summaries
  • Incomplete or conflicting physician documentation (i.e., stroke vs. TIA)
  • Failure to query the attending physician
  • Inaccurate coding
Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent consultant in Madison, WI, offers the following suggestions for CDI specialists:
  1. Stress the importance of a completed discharge summary with physicians. Under the Medicare Hospital Conditions of Participation, records must contain a “final diagnosis with completion of medical records within 30 days following discharge.”

    “Work with your coding staff—they can tell you whose documentation is bad,” Krauss says. Focus your education on physicians that fail to provide completed discharge summaries. 
  1. Develop a hospital specific policy for incomplete or conflicting physician documentation. Work with your HIM/coding staff to determine what constitutes incomplete documentation. For example, many coders won’t report a diagnosis that only appears once in the medical record, whereas some CDI specialists would consider that sufficient based on the presence of clinical indicators.

    “Set clear expectations, or it perpetuates adversarial relationships,” Krauss says.

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