Health Information Management

News: Special MLN Matters article discusses RAC DRG vulnerabilities

CDI Strategies, July 7, 2011

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Inpatient hospital claims submitted to Medicare contain “a significant amount” of incorrect principal diagnoses, according to a Special MedLearn Matters article (SE1121) released June 23. Recovery Audit Contractors (RAC) identified several situations such as coding without a complete discharge note or operative report as contributing factors to error rates.

The article also indicated that facilities may not be evaluating the entire medical record, looking to the emergency department (ED) and/or the history and physical (H&P) to determine the principal diagnosis without consideration of additional laboratory workup or clinical evaluation.

CDI programs which evaluate the medical record during the initial stages of the patient’s stay should continue their review as the stay progresses.
“A complete clinical picture takes time and evaluation to fully develop,” says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent consultant based in Madison, WI.
For example, a CDI specialist may query the physician regarding a possible diagnosis at the beginning of the case “and it turns out after study the diagnosis does not pan out,” says Krauss.”
The coder then assigns a code such as ‘sepsis’ based on the one or two times the diagnosis is documented in the record and the diagnosis does not appear in the discharge summary. “These are the types of mistakes that are being highlighted by the RAC,” adds Krauss.

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