Health Information Management

News: CMS offers partial answer to RAC query submission questions

CDI Strategies, May 13, 2010

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CMS has been holding a number of open forum calls regarding its Recovery Audit Contractor (RAC) programs. Dubbed “Nationwide RAC 101 Calls” these sessions covered the basics of RAC reviews, each focusing on a different provider area.

The first call on April 28, intended for all acute care facilities, offered some interesting insight as to CMS and RAC policy on recovery of the physician query during audits, according to Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc., in Marblehead, MA.
Of particular interest to CDI specialists and their managers were questions raised near the end of the program. The following excerpt is from transcripts of the program:
“Q: I have a question about the appropriateness of the physician query being included as a submission when the RAC asks for additional documentation. I’m seeing conflicting information about whether or not CMS has authorized the query to be a part of what needs to be submitted or if that’s up to the discretion of the particular contractor. 
CMS: Yes, that would be up to the RAC. They can, based on the issue, request what they feel is necessary to conduct the review. If they did not ask for something and you think that it's necessary, then we encourage you to send whatever you think will support paying the claim. 
Q: A sample letter provided by HDI …[includes a] blanket request for a variety of documents. It appears the physician query will be requested on a regular basis. Is that consistent with CMS requirements? 
CMS: Again, that language is fairly standardized. CMS is not prescriptive in what we recommend the provider sending forward. I would send anything that you feel would substantiate a valid payment of that claim. 
Q: Is it required that that query be included every time? 
CMS: It's required that you submit what [the RACs] requesting but we don't have a requirement as to what they can request for their review. If they request that information, you do have to submit it. So in other words, if the RAC requests medical records, you need to submit those documents that you believe will support the claim that was billed. 
Now, the RAC provides some suggestions as to what documents are useful in helping them make the determination. If you don’t believe the physician query helps to support the claim that was billed, then you don’t need to submit it.”
This particular question and answer period should be examined closely for nuances, says Hoy. First, the CMS representative says that RACs can request any documentation “they feel is necessary to conduct the review.” And they stated that “It’s required that you submit what [the RACs] request,” although CMS does not prescribe what documents the RACs can or cannot seek. The issue is further confused by the representatives’ insistence in all three responses that the provider submit any pertinent documentation that would support the claim.
“A simple decision from them as to whether the query is part of the medical record or not could alleviate that confusion,” Hoy says. “But they didn’t say that during this call. Instead, they seem to have indicated that if the facility does not include the query as part of the permanent medical record, and if the query doesn’t support the claim, then the facility doesn’t need to submit the query to the RAC.”
However such ambiguity should prompt facilities to examine their query policies and processes, Hoy says.
“Get your query process and procedures in order and consistent across your facility. If everyone is submitting compliant, non-leading queries that support the documentation in the medical record then what does it matter if the RAC looks at them? If you wouldn’t want to send your query into the RAC, then you probably need to ask why not?”
Answering Hoy’s final question means taking a closer looking at your process for auditing your facility’s queries, says Lynne Spryszak, RN, CPC, CDI education director for HCPro, Inc., in Marblehead, MA.
“Facilities who do not currently have a written query policy and well-defined processes or those who do not have an audit system for their queries could take a hit under RAC review,” Spryszak says.
A CDI program may seem to be progressing well and working effectively but “without an internal query auditing process a facility could suffer at the hands of a ‘Lone Ranger’ out there writing random queries that are non-compliant,” says Spryszak.
While appropriate policies and procedures represent typical CDI best practice, in terms of final definitive answer from CMS from this call, “there just wasn’t one,” Hoy says. “They left it pretty open ended about whether the RAC could request related queries and whether or not a facility needs to comply with that request.”

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