In this episode, Kristi Morris, Director of Revenue Integrity Services at BESLER, discusses five steps to minimize Recovery Audit Contractor denials of Medicare claims.
Mike Passanante: Hi, this is Mike Passanante. Welcome back to the Hospital Finance Podcast.
Today, I’m joined by Kristi Morris who is the Director of Revenue Integrity Services here at Besler. And Kristi has joined us to talk us through five steps to help you minimize RAC denials.
Kristi, welcome to the program.
Kristi Morris: Thank you. Thank you for having me on this morning.
Mike Passanante: Kristi, just for our audience who may not be as familiar with what RACs are or what they do, can you just tell us briefly about them?
Kristi Morris: Sure! Let me just start off with a definition that Medicare has provided for us. The RAC is actually an acronym for Recovery Audit Contractor. The RAC represents the effort to audit healthcare providers on behalf of Medicare and Medicaid to ensure that the healthcare providers are not over billing Medicare and Medicaid. Their primary mission is to identify and correct improper Medicare and Medicaid payments.
Mike Passanante: Thanks for that explanation, Kristi. Why don’t we kick it off with the first step that you’d like to talk through, and that’s “inconsistent documentation.” Why don’t you explain what you mean?
Kristi Morris: Well, health information professionals want documentation to be consistent through the medical record, which is exactly what I think everyone in healthcare wants. However, this is not always the case.
Sometimes, they get a medical record where diagnosis is listed initially, and then it disappears by the time the discharge summary is dictated or they make it a medical record in which the diagnosis is only listed on certain pages, and then omitted from the other pages in the medical record, while other times, they may only get certain physicians such as a consultant that’s even diagnosing the patient with that condition.
Now, these scenarios I mentioned, they do not mean the diagnoses are as invalid or non-reportable. But yet the RACs are looking at these very closely to deny them for inconsistent documentation.
Now, in these cases, I would suggest that you work with your medical staff clinical documentation improvement teams and your HIM professionals to gain consistency. Now this will include having all possible diagnoses listed on the discharge summary and also having your clinical documentation team identifying cases where the diagnoses are not listed consistently throughout the chart.
And lastly, if the case is about to be finalized by your coder, holding that case for query would be the best line of defense on these kind of denials.
Mike Passanante: Kristi, this second step that you have, it may be a little bit similar, but it’s “contradictory documentation.” Can you talk about that?
Kristi Morris: Definitely! Contradicting documentation is just one of the denials that the RAC is using. And it’s exactly what it says, it’s diagnoses that contradict each other.
And some of those most common scenarios that we’ve seen are acute renal failure and renal insufficiency, urosepsis and sepsis, bacteremia and sepsis.
Now, although the physician may use these diagnoses interchangeably, from a coding perspective, the diagnosis cannot be used as one, especially since there’s a specific code for each scenario. So, we just can’t have one code that covers all those diagnoses.
And RACs are taking advantage of that. They’re denying both codes.
Now, although I do understand that querying the physician usually takes time and resources, and even from my experience, most of the time, it takes multiple requests to get the physician to respond, we just believe that this is the only way to really minimize your risk in this area.
Mike Passanante: That’s great. And so, your third step here is a diagnosis that doesn’t meet clinical indicators. Why don’t you tell us about that?
Kristi Morris: Well, currently, one of the most common type of denials is when the diagnosis is listed, but the clinical indicators don’t fit that diagnosis.
For example, a urinary tract infection may be documented throughout the medical record, but the clinical indicators don’t support it. Pneumonia, acute respiratory failure, sepsis, congestive heart failure cases, those are all examples of high risk diagnoses that the RACs are targeting.
And the RACs are using coders, nurses and physicians to identify these cases, and in the end, deny them from that clinical validation standpoint.
The hospital should work together with their medical staff, their CDI group and their coders to identify these cases. And you need to create a proactive approach to reducing your organization’s risk in this area.
And then, in addition, the hospital should train their coders to not only code, but also look beyond the documentation. Look for those clinical indicators. And if you don’t see them, query the physician.
Mike Passanante: Kristi, the fourth step that you’ve listed out here is “the selection of incorrect root operations.” Can you talk to us about that?
Kristi Morris: Yes, with the incorporation of ICD-10 PCS, it is imperative that our coders understand root operations for the procedure. Now, there are 31 root operations in ICD-10 PCS. And selecting the incorrect root operation may lead your coders to encrypt procedure codes, and in return, the wrong MSDRG.
Now, RACs are focusing on procedure codes and trying to identify these codes as potential overpayments. It’s very important that the hospital continue to train their coders with continuing education and internal audits to help minimize these types of denials. That’s very, very important that you conduct the internal audits.
Mike Passanante: And the final step that you’re going to bring us through today is “listing one complication or co-morbidity or one major complication and co-morbidity on the chart.” Can you talk about that?
Kristi Morris: Yes, I think this is one area where the hospitals may be overlooking some low hanging fruit. Cases where there is only one co-morbidity or major co-morbidity or complication listed are potential risks.
So, for instance, if a patient comes in for an appendectomy, and they develop an acute blood loss anemia, a hospital would assign the appropriate code for the acute blood loss anemia.
Now, in this scenario, the RAC would focus on making sure the documentation is appropriate and valid by reviewing the clinical indicators. Hospitals need to identify these as only one complication or co-morbidity cases and make sure that everything from a documentation and a clinical indicator perspective has been reviewed and validated to prevent a denial on this end.
These are ones that are highly predictive for audits.
And one thing I want to mention is that these areas that we briefly touched on today, these are just a few of the areas that we’ve seen the RACs focus on in the past. Now, the key to staying ahead of direct audits is instituting a proactive approach to improving documentation.
And this can occur in multiple, multiple ways—whether it’s through education and refresher courses or timely analysis of your denials.
And one key to the timely analysis of your denials is not just looking at your denials and doing a simple analysis and knowing where your denials fall, but as a result of that analysis, making changes in your organization’s future processes. That is the key.
If you see that you’re having an issue in one service line or with one of your physicians, the key is addressing that issue and then changing it going forward.
Healthcare is ever changing. Therefore, the ability to analyze and adjust quickly is essential.
Mike Passanante: Kristi, thank you for walking us through those five steps. I think you were very informative. Before we leave you today, for our audience, we just wanted to mention something that Kristi’s been working on, and that is the development of a revenue integrity service here at Besler. We think it’s a very novel approach to attacking the revenue integrity problem. And we’re going to be launching that offering officially at HFMA’s ANI meeting in Orlando this June.
So, if you’re at that meeting, please stop by our booth which is #1514. We’ll be happy to talk to you about that. Or continue to visit our website for the latest updates because it should be a very exciting summer for us and hopefully for you as well as we roll out this new revenue integrity service.
So, thank you for your work on that, Kristi. And thanks for the great information today.
Kristi Morris: Alright! Thank you.