Health Information Management

News: Identify potential Medicaid RAC target areas

CDI Strategies, May 24, 2012

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The Medicaid RAC program kicked off January 1. Although the program got off to a slow start, activity will likely ramp up in the next few months. So if your hospital hasn't experienced a Medicaid audit yet, it probably will soon. As audits get under way, specific target areas will begin to emerge as well.

Addressing documentation, coding, and billing problems ahead of time is the best way to prepare for Medicaid RACs, says William L. Malm, ND, RN, CMAS, a healthcare consultant at Craneware in Atlanta.
"Are you putting that effort in on the front end to make sure that the claim is as clean as possible before it goes out?" asks Malm "Clearly, the front end [route] is going to be most cost-efficient."
Physicians need to understand and appreciate the role they play, says Elizabeth Lamkin, MHA, CEO and partner at PACE Healthcare Consulting, LLC, in Hilton Head, SC. "A third party has to be able to look at [physician] notes and independently validate the inpatient stay," she says.
Documentation of the history and physical should include an explicit explanation of the patient's severity of illness, says Lamkin. Physician orders should reflect the intensity of the services provided. Problem notes must also justify the ongoing intensity of a service that supports a continued stay, she says.
Physician advisors can help coders and CDI specialists better partner with medical staff, says Lamkin. "This role is the bridge between physicians and the facility," she says. Physicians, coders, and other staff must understand payer rules, state-specific coding and sequencing requirements, and the appropriate clinical documentation needed to justify services.
Editor’s Note: This article is an excerpt from the April issue of Briefings on Coding Compliance Strategies.

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