Health Information Management

News: CDI efforts in pre-payment reviews on the rise

CDI Strategies, January 16, 2014

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Of the nearly 450 respondents to a recent ACDIS website poll, 50% say they conduct pre-payment record reviews, with an additional 7% indicating their facility is considering implementing such reviews in 2014. Of that 50%, 35% of CDI departments conduct such reviews themselves.
“CDI pre-bill reviews are becoming more common,” says Cheryl Ericson, MS, RN, CCDS, CDIP, CDI Education Director at HCPro Inc., in Danvers, Mass. The difference between a concurrent review and a pre-payment review is the availability of the discharge summary, which can contain key documentation.
Pre-payment reviews occur following discharge and possibly following coding, but prior to billing, so the CDI staff presumably has the complete record. This type of review works well for those short-stay admissions where the patient is discharged before a concurrent review can occur as these cases are often vulnerable to medical necessity denials. 
On the payer side, pre-payment reviews work as follows: Contractors such Medicare Administrative Contractors (MACs) and Recovery Auditors (RAs) request the medical record to vet the record and ensure the medical necessity for the inpatient admission or possibly to determine if the correct DRG was assigned prior to paying for the care, says James Kennedy, MD, CCS, CDIP, principal at CDIMD Physician Champions in Smyrna, Tenn.
RAs are conducting pre-payment reviews in nearly a dozen states, and more states are expected to see similar reviews as CMS renews/expands its contracts in 2014, he says. As announced by CMS, MS-DRGs currently under review are 312, Syncope and Collapse; 69, Transient Ischemia; 377-379, Gastrointestinal Hemorrhage; and 637-639, Diabetes. Learn more at the following website
CDI efforts in the concurrent realm (while the patient is still in the hospital) take place within an evolving environment, says Kennedy. The patient’s condition evolves and the care the physician provides evolves as well. In contrast, he pre-payment realm typically takes place in a static post-discharge environment. The patient’s condition evolved enough to be sent to a different setting and the record is theoretically as complete as possible.
“With a solid process in place, pre-payment reviews represent another pair of eyes that ensure the veracity of the bill before it gets dropped,” says Kennedy. “You don’t want anything going out the door that isn’t what it is supposed to be.”
Optimally, CDI specialists should review pre-payment records to ensure that the coded information is consistent and precise, and representative of all the documentation improvement efforts up to that point. They would help reconcile or escalate any cases as necessary and communicate back to the rest of the CDI and coding team any concerns which seem particularly problematic, or rise to the level or warranting additional educational focus.
Of course, pre-payment reviews shouldn’t be so onerous as to hold up the coding and billing processes but rather employed as a final check for compliance, Kennedy says.

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