IPPS, RAC, etc

dbutler

I've pulled a summary from the most recent CDI Strategies and RAC
Monitor e-newsletters (I am sure everyone gets CDI Strategies, RAC
Monitor is one of several other ones from HC Pro well worth it). Hope
this is helpful.

The IPPS final rule is out:

** The documentation and coding adjustment of -2.9% was applied. CMS
is required to apply a total of -5.8% by FY12 to recoup overpayments (so
they argue) in 08 & 09, so anticipate the same next year. This is
partially offset by updated acute rates of 2.35%. The net is -0.55%.

** ARF / AKI is now a CC.

** Seems CMS will be focusing on ENCEPHALOPATHY next year.........their
next target to decrease their payments. Really not a surprise though.

** There is a clarification of the 3 day rule

** CMS is adding the following eight categories of conditions included
on the HAC list:
* Foreign object retained after surgery
* Air embolism
* Blood incompatibility
* Pressure ulcer stages III and IV
* Falls and trauma (including fracture, dislocation, intracranial
injury, crushing injury, burn, and electric shock)
* Vascular catheter-associated infection
* Catheter-associated urinary tract infection
* Manifestations of poor glycemic control
There are two additional patient safety Indicators:
*postoperative respiratory failure and
*postoperative pulmonary embolism or deep vein thrombosis.

LINK for more info:
http://www.hcpro.com/HOM-254590-6962/CMS-proceeds-with-documentation-29-payment-cut-in-FY-2011-IPPS-final-rule.html


Apparently, some RAC's are denying post discharge queries. What is not
completely clear from the blog post is whether this is only queries that
are posed in response to an external rule, or if it is all
post-discharge queries. Seems there is the possibility it is all. BUT,
this issue will certainly be argued.

From the blog post linked below:
"...ultimately the issue boils down to the fact that it is usually a
problem that can be avoided by tightening up documentation practices on
the front end.
“Ideally a facility will have a full-fledged working team comprised
of physicians, clinical documentation specialists, and HIM/coding
professionals to work together to identify those cases where
clarification needs to be made prior to discharge,” she says. “To
put it bluntly, just make sure to have a robust and fully functioning
CDI program in place." "

http://blogs.hcpro.com/revenuecycleinstitute/2010/08/racs-denying-post-discharge-queries/


The fun never ends, does it? Keeps us busy and productive!!

Don

tkreiling

Thanks for sharing, I find the post discharge querying information very interesting. We sometimes have to query post discharge, especially for path results as alot of the time the results are not in until the patient is discharged or if the coder finds something that I had missed.

dbutler

I hope everyone reads that particular piece carefully.
It is NOT clear to me whether or not RACs are denying all post-discharge queries.........

Don

dog

Not having gone through the RAC process yet, I am wondering what recourse the hospitals have after a RAC rampage. Just because they say something is so, does that make it so? And do their decisions cross RAC boundaries (in the same way that a court decision in one state is not necessarily binding precedent in another state)? Are the coding clinics going to be rewritten, too?

Just another inquiring mind...

Renee

Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

dbutler

"RAC Rampage" -- feels like that with the internal pressure......like that turn of phrase

There is a defined process for appeal and actually a fair amount of information if you go digging about that.... not too bad actually. The third level is with an Administrative Law Judge -- so I believe there is influence there across boundries. The individual RACs don't seem to be in total synch -- so suspect there is some variation at the front end.

Personally, don't think the coding clinics will directly be affected, on the other hand, I am sure that folks 'in the field' will be influenced by RAC activities with the questions they submit.....

FYI -- seems like the coding clinics for ICD9 will not translate for ICD10. Something on the ACDIS blog about that recently -- July 19 "Coding Clinic does not plan to convert previous guidance"
http://blogs.hcpro.com/acdis/2010/07/coding-clinic-does-not-plan-to-convert-previous-guidance/

Don

kshumpert

We have appealed decisions that RAC has made. I know that we pay attention to what is happening in other regions because RACs will share information. We have found that some of the redeterminations that our RAC has made are based on information from another region and not applicable in the same timeframe. We are waiting to see if those issues are overturned. Does anyone track the RAC cause for redetermination? Specifically, do you log their argument to check for consistencies in patterns? I just wondered if it would possible help with some of the appeals to use their own information in an argument.

lspryszak

When you read that blog post about the RACs denying post-discharge queries, the example given was a facility who queried the physician after they had already received a request for overpayment (denial) of 86.22, excisional debridement.

I think the RAC's decision was based more on the fact that the post-discharge query was initiated after their decision to deny the payment.

I don't think that post-discharge, pre-bill queries would be affected -- but that's only my opinion. I would just say that all these target cases should have a second- or even third-level review for documentation and accuracy prior to final billing in order to mitigate RAC risk on target DRGs or specific codes.

If facilities are querying in response to a denial, then the query is probably perceived poorly -- trying to get the doc to change his/her documentation just to overturn the denial.

I think that case referenced in the blog post is truly a cautionary tale: concurrent review + concurrent queries is always better than post-discharge (or post-denial) review. At that point it's too late.

Of course, as we all know, if you don't have enough staff to do a thorough job on the front end, you'll end up paying on the back end...

Hopefully administrators will get the message. We all know that the cost of one CDS will ultimately be a whole lot cheaper than the cost of numerous RAC appeals.

sbeatty

Thanks for that clarification! That makes much more sense. I also agree
wholeheartedly with the caveat about the cost of a CDS vs. the cost of
denials

Sandy Beatty, RN, BSN, C-CDI
Columbus Regional Hospital
2400 E. 17th Str.
Columbus, IN 47201
(O) 812-376-5652 (M) 812-552-6997


"Great leaders are almost always great simplifiers, who can cut through
argument, debate, and doubt to offer a solution everybody can
understand."

General Colin Powell