YPRO Article
CMS Releases Two Pertinent MedLearn Matters Articles Related to RAC Vulnerabilities
Medicare on September 23rd released two pertinent Special Edition MedLearn Matters Articles with tremendous relevance to coders and clinical documentation improvement specialists. The first article, is SE1027 entitled Recovery Audit Contractor (RAC) Demonstration High-Risk Medical Necessity Vulnerabilities for Inpatient Hospitals, and the second article is SE1028 Recovery Audit Contractor (RAC) Demonstration High-Risk Diagnosis Related Group (DRG) Coding Vulnerabilities for Inpatient Hospitals. You may access these two articles by clicking on the links below:
http://www.cms.gov/MLNMattersArticles/downloads/SE1027.pdf
http://www.cms.gov/MLNMattersArticles/downloads/SE1028.pdf
These articles introduce many key points and considerations that directly impact medical necessity for inpatient admission, coding and clinical documentation improvement efforts through clinical documentation improvement programs. The following MS-DRGs were identified as problematic from a “medical necessity” inpatient admission standpoint in conclusion from the RAC Demonstration project:
- Cardiac Defibrillator Implant (DRG 514/515) MS-DRG 2260227
- Heart Failure and Shock (DRG 127) MS-DRG 292-293
- Other Cardiac Pacemaker Implantation (DRG 116) MS-DRG 243-244
- Chest Pain (DRG 143) MS-DRG 313
- Misc. Digestive Disorders (DRG 182) MS-DRG 392
- Other Vascular Procedure (DRG 478) MS-DRG 253-254
- COPD (DRG 88) MS-DRG 191-192
- Medical Back Problems (DRG 243) – MS-DRG 552
- Nutritional & Misc. Metabolic Disorders (DRG 296) MS-DRG 641
- Transient Ischemia (DRG 524) MS-DRG 69
- Other Circulatory System Diagnoses (DRG 144) MS-DRG 316
- Kidney & UTI (DRG 320) MS-DRG 690
- Cardiac Arrhythmia (with CC DRG-138) MS-DRG 310
- Degenerative Nervous System Disorders (DRG 012) MS-DRG 57
- Atherosclerosis (with CC DRG-132) MS-DRG 303
- Other Digestive System Diagnosis (DRG 188) MS-DRG 395
- Percutaneous Cardiac Procedure (DRG 517) MS-DRG 251
These inpatient admissions falling under the above listed MS-DRGS were deemed to be not medically necessary under the pretext of place of service setting. The same level of care may have been provided in an observation status. Medicare points out in its article that the contributing factors to medical necessity denials were incomplete and insufficient documentation to support the physician’s clinical medical decision-making and clinical judgment for inpatient admission. This insufficient clinical documentation was necessary to:
- Support the diagnosis submitted on the claim,
- Justify the treatment/procedure,
- Document the course of care,
- Identify treatment/diagnostic test results, and
- Promote continuity of care among healthcare providers
Other issues to consider as outlined in the article include:
- The medical record must contain sufficient documentation to demonstrate that the beneficiary’s signs and/or symptoms are severe enough to warrant the need for inpatient medical care
- Providers should document any pre-existing medical problems or extenuating circumstances that make admission of the beneficiary medically necessary.
- Entries in the medical record are consistent with other parts of medical record (assessments, treatment plans, and physician orders, nursing notes, medication and treatment records, etc. and other facility documents such as admission and discharge data, pharmacy records, etc.)
- Providers should adequately and sufficiently document significant changes in the patient’s condition or nonresponsive to treatment, documentation necessary to support the need and justification for inpatient admission versus observation status.
From a coding perspective, facilities should take note of two “reminders” provided by Medicare in the article, each of which is in direct contrast to official coding guidelines governing selection of principal and secondary diagnoses. The first reminder is “all inpatient admissions must have the principal diagnosis specifically identified by the attending physician” and the second reminder is “All inpatient admissions must have all “other” or “secondary” diagnoses identified by the attending physician. Most recently the permanent RACS have used as a justification for invalidating ICD-9 code assignment the fact the diagnosis coded was absence from the discharge summary. CMS addressed this RSC rationale for invalidation of code assignment through its recommendation that the principal diagnosis as well as secondary diagnoses be documented in the medical record and discharge summary.
Next Steps
In light of the content of the two recently released Special Edition MedLearn Matters RAC vulnerability articles, now is the time to conduct an audit and review of your current hospital policies and procedures governing the determination of medical necessity for inpatient admission versus observation? Determine whether commercially available admissions screening criteria are consistently being applied in providing guidance to physicians on the appropriateness of inpatient admission as opposed to observation. Conduct an audit and review of the above listed potentially problematic MS-DRGs from a medical necessity perspective, assessing the adequacy, completeness, and effectiveness of clinical documentation in support of inpatient admission beyond meeting of severity of illness and severity of illness inpatient medical necessity criteria. Recognize that screening criteria is just that, screening and the physician’s clinical judgment and medical decision making do play an active role in determining the appropriateness of inpatient admission, provided the physician’s documentation accurately reflects his/her clinical judgment, patient risk factors and medical decision making in the management of the patient. In planning, organizing and carrying out these necessary audits and reviews, consider the best approach, in-house versus outside consultant, and which will provide the facility with the most objective assessment with a specific, accountable and measurable action plan to correct any identified deficiencies in the medical inpatient admission medical necessity process.
Now is also an ideal time to assess the adequacy and effectiveness of your facility’s clinical documentation improvement program in affecting positive change in general physcian patterns of clinical documentation. Determine to what extent the principal diagnosis and secondary diagnoses are solidified and appear throughout the record including the discharge summary. Determine whether the coders are using documentation that appears only once or twice in the record in the code selection and assignment process without taking into account the supporting clinical information in the record. Determine also whether coders are using the physicians response to a query form generated retrospectively after the patient has been discharges from the hospital as the basis for assigning a principal and secondary diagnoses without this information in the discharge summary. You may need to update your policies and procedures governing ICD-9 and MS-DRG code assignment in light of the identified RAC vulnerabilities as outlined in the two MedLearn Special Edition articles.