second level reviews

sbeatty

What are the rationales and procedures (briefly) for second level
reviews in your organizations? Who does them? How often? Feedback
mechanisms, etc.



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

dallend@einstein.edu

We define 2nd level reviews as a disagreement with a coded DRG (princ dx) or a diagnosis/procedure documented in the chart but not coded.
We refer these back to the coder for review most of the time.
If it is a princ dx we may have the compliance manager review the chart first.
Many times coders will send 2nd level review charts to the compliance manager or coding manager anyway.
Usually it is resolved easily. Once in a great while a chart will have to be reviewed by our Director.

cmorell

We do "second level reviews" for any charts with LOS greater than 4 days without CCs or MCCs. Just to take a look to make sure there are no diagnoses that can be clarified to justify a longer length of stay/medical necessity, risk of mortality, severity of illness.
Coding will put these in our box to review. We are also looking at mortality reviews, any charts where patients expired to make sure the documentation was reflective of the medical necessity, ROM/SOI, etc. You wouldn't expect someone to die of syncope, UTI or weakness.

dallend@einstein.edu

Our second level review process includes: principal dx differs, CC/MCC documented but not coded, diagnosis coded but not documented, procedure/s not coded. I track the second level reviews. Our compliance manager tracks other issues.

lspryszak

Second-level reviews can be done for several reasons, some of which have already been mentioned in this thread: DRG reconciliation, etc. Another good reason to implement second-level reviews is to double-check those records with only one CC or MCC, or to validate those diagnoses and procedures targeted by the RAC (sepsis, respiratory failure, excisional debridements). Extra time spent on the front end (pre-bill) is always cheaper than fighting recoupments on the back end. Since we know what the target issues are, it makes sense to have those risky charts validated before the final codes and bill go out. Then you don't have to worry about them, no matter which auditor is involved.

Cases with diagnoses that our coders felt were questionably supported by the record went to our physician advisor, who then performed a review of the record from a clinical perspective. If he felt that the condition was there, but the documentation was lacking, he would call the physician of record, discuss the case, and the record was flagged as "deficient" until the physician could add additional documentation. This was a great resource for the coding team.