RAC- audit
I just received a letter from IFMC (Iowa Foundation audit for medicare). It was
forwarded to me by my director. In the letter it was addressed to the primary
physician in regards to her secondary diagnoses. This patient was admitted with
pneumonia. In her H&P, she indicated hx of CHF, and in her progress note, she
wrote "chronic systolic HF". She also documented "acute on chronic renal" in her
H&P as well. We, the CDSs did not have to ask her on type of CHF, she already
done that for us. However, she had an in complete dx: "acute on chronic renal".
Therefore, one of us asked her what she meant, and she wrote back "acute on
chronic renal failure".
Now, the IFMC indicated in the letter that pt was tx'd for her CHF nor for her
Acute Renal failure. Therefore, those two dxs should be taken out, leaving only
DRG 195. Further review on this record with my PA found this:
1. Patient did have hx fo CHF, and on her previous admission, physician did
document the same thing. Pt was on PO lasix at that time. On this admission, no
po lasix given. No IVF given.
2. Could PMD w/held po lasix this time d/t increased in creatinine level? She
did mention in her note that she would continue to monitor pt's renal status.
3. Our coders query physicians left and right whenever they see "CHF"
documented, therefore, our docs are all trained to document the specifics for
us. Isn't this a requirement from MDCR coding?
4. Clarifying the documentation in the chart is part of our job, right?
My PA (physician advisor) will be speaking to this primary physician, and
together, they will write a letter back to IFMC. We will see what happens.
forwarded to me by my director. In the letter it was addressed to the primary
physician in regards to her secondary diagnoses. This patient was admitted with
pneumonia. In her H&P, she indicated hx of CHF, and in her progress note, she
wrote "chronic systolic HF". She also documented "acute on chronic renal" in her
H&P as well. We, the CDSs did not have to ask her on type of CHF, she already
done that for us. However, she had an in complete dx: "acute on chronic renal".
Therefore, one of us asked her what she meant, and she wrote back "acute on
chronic renal failure".
Now, the IFMC indicated in the letter that pt was tx'd for her CHF nor for her
Acute Renal failure. Therefore, those two dxs should be taken out, leaving only
DRG 195. Further review on this record with my PA found this:
1. Patient did have hx fo CHF, and on her previous admission, physician did
document the same thing. Pt was on PO lasix at that time. On this admission, no
po lasix given. No IVF given.
2. Could PMD w/held po lasix this time d/t increased in creatinine level? She
did mention in her note that she would continue to monitor pt's renal status.
3. Our coders query physicians left and right whenever they see "CHF"
documented, therefore, our docs are all trained to document the specifics for
us. Isn't this a requirement from MDCR coding?
4. Clarifying the documentation in the chart is part of our job, right?
My PA (physician advisor) will be speaking to this primary physician, and
together, they will write a letter back to IFMC. We will see what happens.
Comments
If the patient has a diagnosis such as CHF but is not being treated during the admission the MD needs to document why they are withholding the medications. The same for the renal failure. We have been denied payment because the labs and treatment did not support the diagnosis. I do want to say that we do not review Medicaid charts at this time.
After doing several record audits for DRG validation with an eye toward RAC liability I would just say this:
If you have any final DRG assignments with only one MCC combined with a relatively short length of stay, these records are sure to be targeted by the RAC. They will stick out like sore thumbs when your DRG data is crunched by an auditor, and will likely be targets in the future for complex reviews.
It's too late to go back and do anything about the records going back to 10/1/07 (the look-back date) but it's not too late to institute pro-active processes now.
One of the many issues under RAC scrutiny are high-weighted medical DRGs with short lengths of stay. Currently the contractors all seem to be saying that medical necessity reviews are excluded (whew!)but those are coming, too.
I would encourage everyone to develop a "second set of eyes" review process for ALL DRG cases with only ONE MCC. This can be done concurrently by asking a CDS colleague to take a "peek" and see what he/she thinks: does the patient's condition, treatment plan and documentation clearly support the MCC? Then, after discharge, have your DRG analyst or coding manager do a second look before the bill is dropped.
Considering CHF or some of the other DRGs - the reimbursement isn't much to begin with but the appeal process will cost a lot more than the extra time spent on this front-end process.
See Coding Clinic 2nd Q 1992, pg 16-17, " COPD is a chronic condition which would affect the patient for the rest of his life. Therefore, if there is documentation in the medical record to indicate that the patient has COPD, it should be coded. If the physician mentions the COPD only in the history section and then again on the attestation with no contradictory information, the condition should be coded. The same would be true for other chronic conditions such as diabetes mellitus, hypertension, and Parkinson's disease".
Kim Carr, RHIT, CCS
Core Measure and Clinical Documentation Improvement Manager
Care Management
Erlanger Medical Center
975 East Third Street
Chattanooga, TN 37403
phone # 423-778-4225
email-kimberly.carr@erlanger.org
Life isn't about how to Survive the Storm, but how to Dance in the rain!!!!
department to look at all DRGs with 1 MCC or 1 CC. He made sure those were
supported by clinical record before bill is dropped. The process started last
year, and lasted about 9 months. The PA found no "up coding". He stopped his
auditing because he felt we were doing a good job.
Unfortunately in the case I mentioned. This doctor does not have the best
documentation especially when she is in a hurry. I think she w/held lasix when
she saw renal panel going up, but did not want to give much fluid. We are going
to attempt to talk to her and see her rationale.
Do all your coders ask for CHF specificity?
looking at short stays (
My physicians have been trained in specificity, but they're unlikely write specificity on their own if they're not treating it, so I haven't run into this problem.
I have been known to ask physicians to update their documentation to cancel clinically inappropriate diagnoses. For instance, I have an internist who was labeling all ventilated patients whom he saw immediately post-op in the recovery room as ventilator-dependent respiratory failure. I had to pull up a number of journal articles (he is very research-oriented) to show him that this is not the documentation standard both medically and coding-wise. I'd rather take the financial hit now than deal with the repercussions later.
Linda Renee Brown, RN, CCRN
Clinical Documentation Specialist
Arizona Heart Hospital
--Juan
out for MD to see, or write the EF on the query. Our physicians here have been
drilled to do echo when they have a CHF patient, and none for past 6 months.
(part of core measure)
The problem is that if it is required for us to report CHF specificity, why are
they asking to take that secondary dx out?
--Juan
We do not question MD diagnoses once they are documented. What we try to do is educate the physicians re: appropriate documentation based on pt condition, s/s when we do our education. We have a very old school hospital. In addition, when we were trained we were told it not CDI responsibility to question a diagnosis once it is written by the MD, however we can educate them regarding appropriate documentation when we to our inservices.
Kim
for the physician's reference.
Gina Spatafore, RN
Clinical Documentation Integrity Specialist
Waterbury Hospital
203 573 7647