CDI’s Impact on the Recovery Audit
Contractor
Capitalizing Upon Our Strengths to Minimize
Hospital Financial Exposure
Objectives
 Highlight and describe
the effects of clinical and coding interpretation upon risk of
pre and post payment chart audits and their financial
implications
 Outline the merits and supporting role
of “quality” clinical documentation on financial exposure
reduction inherent to internal and external medical record
audits common to third party payer provisions
Objectives
 Collaboration
Recognize how CDI specialist can work in collaboration with
case management, utilization review and revenue cycle denial
teams in a prospective manner as part of a CQI initiative to
learn from “mistakes” and reduce denials
Objectives
 Understand
how the CDI Specialist can play and active role in the RAC
process, building upon the fundamental premise of CDI
beyond reimbursement that incorporates a holistic approach
to effective clinical documentation improvement.
CMS Policy Guidance
Program Integrity Manual Guidance
 Review
Chapter 6, Section 6.5.1, of the Medicare Program Integrity
Manual requires that contractor review staff use a screening
tool as part of their medical review process for inpatient
hospital claims.
 CMS does not require that the contractor use specific criteria
nor endorse any particular brand of screening guidelines.
 CMS contractors are not required to pay a claim even if
screening criteria indicate inpatient admission is appropriate
CMS Policy Guidance
Program Integrity Manual Guidance
 CMS Contractors are not required to automatically deny a
claim that does not meet the admission guidelines of a
screening tool
 In all cases, in addition to screening instruments,
the reviewer shall apply his/her own clinical
judgment to make a medical review determination
based on the documentation in the medical record.
For each case, the review staff will utilize the
following when making a medical necessity
determination
 Admission criteria
 Invasive procedure criteria
 CMS coverage guidelines
 Published CMS criteria
 Other screen, criteria, and guidelines (practice guidelines that
are well accepted in the medical community)
Factors that need to be considered when
making the decision to admit
 Physicians should use a 24-hr period as a bench mark
 They should order admission for patients who are expected
to need hospital care for 24 hours or more
 However the decision to admit a patient is a complex medical
judgment
Which can be made only after the physician
has considered a number of factors
 Patients medical history
 Current medical needs
 Types of facilities available and the appropriateness of
treatment in each setting
Other factors to consider
 The severity of the signs and symptoms exhibited by the
patient
 The medical predictability of something adverse happening to
the patient
What is the Purpose of Documentation
 To show that the service was medically necessary
 To justify billing the service at the level billed
 To demonstrate that the standard of care was met, if
needed, to defend against an action for malpractice
 To assist clinicians who follow in performing subsequent
care
Documentation Impacts
 Medical necessity
 Coding applications
 Data integrity
 Quality Concerns
 Patient safety
 Continuity of care
 Appropriate reimbursement
 Physicians case mix index and E/M
Case Study 1
 86 yr old male
 UTI
 Admitted 4 day LOS
 Insurance wants to change from Inpatient to Observation
Case study 2
 Presents with chest pain as obs status ptca procedure
changed to inpt status
 Medical PDX coded as CAD w/ ptca /stent and AMI as
MCC outside auditor wanted the AMI as the PDX with no
MCC
Coding Rules
 If it’s not absolutely clearly documented – we cannot code it.
 Example
 Hemorrhage after surgery – Hg 5 – Two units PRBC
 Cannot accurately code hemorrhage.
 Cannot code blood loss anemia.
 Cannot code anemia.
More Coding Rules
 Pathology, radiology, or laboratory reports present in the
chart, but not reviewed and interpreted, essentially do not
exist for coding purposes.
 We cannot “interpret” the results – only the attending
physician can.
 Do not use symbols. These are not visualized by the coders.
Poll of WI ACDIS Members
 Thanks to all that responded
Does your facility have some
kind of RAC team?
1.
2.
3.
4.
I believe so
Yes
Yes
Yes, we have a RAC team at each site as well as a RAC
Steering committee for our System
If yes do any CDIS serve a role on this team
No
2. No
3. Yes
4. CDIS are members of most teams. CDI and coding
partner to write any DRG letters with clinical focus.
1.
Top 3 reasons for denials (from survey)
This has not been shared with the CDIS
2. Medical Necessity, Excisional Debridement, Major small &
large bowel procedures, Cardiac Value & other Major
Cardiothoracic Procedure, Disease and disorders of the
Respiratory system, Intracranial Hemorrhage or Cerebral
Infraction
3. CDI denials: AKI/ARF, alternative principal diagnosis,
ABLA,, rhabdo vs ARF.
- Coding denials: Sepsis vs Pneumonia
1.
What process do you have for denials
1.
2.
3.
Not sure as formal process has not been shared with CDIS,
but I believe the Coding Supervisor has a role in this.
Yes we have a process.
We have a central RAC office for communications using
RAC tracking software.
Does CDIS have a role in this process
No
2. No
3. Yes
4. Yes
1.
Process for when CDIS and coders disagree.
1.
2.
3.
CDIS emails form with information regarding case to
Coding Supervisor who reviews case and responds to
CDIS.
We no longer compare.
Review to see how we came up with DRG if needed then
go to head of coding.
Process for when CDIS and coders disagree
4. Collaboration and compromise
Any Case to share
 If not documented in discharge summary RAC is saying it is
conflicting information. Renal failure vs Renal insufficiency
 Clinical documentation missing word acute – blood loss
anemia
Discussion
 Would it be more effective
for CDI to reinforce the concepts of documentation
reflective of the reporting of physicians' clinical judgment,
medical decision making and amount of work performed or
to spend most of their time focused on capturing
CC’s/MCC’s and PDXs without supporting documentation
from physician in the record?
Reason for Denials
 The medical record was not received on time.
 The claim was not submitted on the appropriated bill type.
 The medical records did not substantiate the medical
necessity for the level of care billed
 The documentation did not adequately support the services
billed
Reasons for Denials
 The documentation did not show that the billed services
were rendered to the patient.
 The physician ordered outpatient but an inpatient claim was
filed
 The physician orders and progress notes did not provide
sufficient information for the purpose of treatment, medical
or surgical interventions
Reason for Denials
 The patient’s condition, reason for procedure, surgical
intervention or need for an implantable device were not
documented in the medical record
 Interdiscipliary team members did not chart
 Assessments identifying a medical condition requiring
interventions
 Barriers to discharge
Reason for Denial
 Interdiscipliary team members did not chart
 Assessments identifying a medical condition requiring
interventions
 Barriers to discharge
 Actual interventions used to address assessment abnormalities
 Evaluation of services rendered to the beneficiary indicating the
patient’s response to services
What Should be Documented
 The patients condition
 The patients need for services and prior failed interventions
 The plan of care to address the patient’s specific health care





needs
The results of lab test, x-ray and other DI results ordered by
the physician.
The risk factors complicating the patient’s health condition
The patient’s response to surgery, procedures, medical
interventions and therapies
Progress made in the patient’s condition and POC
Any setbacks
What Should be Documented
 Any barriers to treatments, complications that need to be
addressed before other treatments can be initiated.
 H&P information and risk factors influence physician
treatment decisions that present risk that reduces the
improvement of the patient’s condition
Documentation Tips for Physicians
 Review dictations to determine if the information is correct.
 When ordering a change in the patients status, clearly
document the clinical reasons for the change.
 Validate verbal and phone orders with a legible signature,
credentials and date. Ensure physician cosigning signature is
clear and legible.
Document Tips for Physicians
 When a patient is admitted as an inpatient, clearly indicate
the diagnosis or major concern that would need to be
managed in the inpatient setting.
Documentation Tips for Physicians
 The physician should document the progression of the
patient’s condition. Tell the story of what and why each
services has been ordered. Also document the condition of
the patient after ER treatment, if the patient is admitted
Documentation Tips for Inpatient Staff
 Clearly document the patient’s presentation and clinical
assessments
 Provide room air saturations with vital signs including on
discharge.
 For patients with vomiting and diarrhea , document the
number of episodes and the consistency of the stools and
emesis. If none was observed document this also
Documentation Tips for Inpatient Staff
 Clearly document IV fluids and IV medications.
Documentation of start times and stop times. Document
rates and describe IV routes as PICC line, Central line, etc.
 Avoid writing over other entries in the chart. Overlapping
entries distorts the documentation and reduces legibility
making it difficult to determine what was written
 Ensure that the documentation supports the plan of care,
interventions and treatments. Also document the patient’s
response to the treatment
Documentation Tips for Medical Records
 Ensure all documentation in the ADR ( additional
development request, denial, appeal)is provided for medical
review
 Ensure that the medical record is in order and provides a
complete picture of what occurred on each day.
 Ensure that all documentation is provided in a manner and
size
Thank You
 Questions
 Discussion