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What’s New with RAC 2?Audit findings, Updates, and Operational Ideas

Instructor: Day Egusquiza, PresAR Systems, Inc

RAC 2011 1

To ensure billed services are reflected in the documentation in the record

To ensure billed services are in the medically correct setting for the pt’s condition

To ensure billed service reflect the ‘rules’ regarding bill for the specific service

To ensure documentation can support all billed services according to the payer rules.

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Common issues:◦ Dept staff not understanding the charge capture

must match physician order and documentation.◦ Lack of ongoing coder education◦ Lack of ongoing dept head ed◦ Lack of physician understanding◦ Creating a culture of audit – time to be pro-activeg p

RAC 2011 3

Commitment to Reduce the Error President Obama recently announced the y

government’s commitment to reduce the error rate by 50% (using a baseline of 12.4%) by 2012 (2008 3.6% $10.3 Billion )

– 9.5% for November 2010 Report – 8.5% for November 2011 Report – 6.2% for November 2012 Report Thru MAC, CERT, ZPIC, RAC, MIC, OIG, HEAT auditing… Funding PPACA by eliminating fraud, waste and abuse…

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Entity Type of claims

How selected

Volume of claims

Purpose of review

QIO Inpt hospital All claims where hospital submits an adj claim for a higher DRG.Expedited coverage review requested by bene

Very small To preventimproper payment thru upcoding.To resolve disputesbetween bene and hospital

CERT All Randomly Small To measureimproper payments

MAC All Targeted Depends on # of claims with

To prevent future improper paymentsclaims with

improper paymentsimproper payments

RAC All Targeted Depends on the #of claims with improper payments

To detect and correct pastimproper payments

PSCZPIC All Targeted Depends on the # of potential fraud claims

To identifypotential fraud

OIG All Targeted Depends on the # of potential fraud claims

To identify Fraud

RAC 2011 5

Updates Impacting the Auditing of ClaimsAuditing of Claims

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• Focusing on curbing fraud, waste and abuse in the Medicare program.

• Time period for filing Medicare FFS claims in Section 6404 of the PPACA d d th ti l fili i t t d thPPACA amended the timely filing requirements to reduce the maximum time period for submission of all Medicare FFS claims to one calendar year after the date of service.

• Under the new law, claims for services furnished on or after Jan 1, 2010 must be filed within 1 calendar year after date of service. In addition, mandates that claims for services furnished before Jan 1, 2010 must be filed no later than Dec 31, 2010.

• The following rules apply to claims with dates of service prior to Jan 1, 2010: claims with dates of service before Oct 1, 2009 must follow the pre-PPACA timely filing rules Claims with datesmust follow the pre PPACA timely filing rules. Claims with dates of service Oct 1-Dec 31, 2009 must be submitted by Dec 31, 2010.

• Impact on denied claims with rebill potential with the RAC and MIC?

RAC 2011 7

Requires report and repayment of overpayments.

“Overpayment’ = funds a person receives or retains to which person is not entitled after reconciliation.

Providers and suppliers must: Report and return overpayments to HHS, the state or contractor by the later of:◦ 60 days after the date the overpayment was identified or◦ The date the corresponding cost report is due.P id itt l ti f th f tProvide a written explanation of the reason for overpayment

(PPACA 6402)Retaining overpayments after the deadline for reporting is

subject to False Claims Act and Civil Monetary Penalties law.

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SE1024 “RAC: High Risk Vulnerabilities- No documentation or insufficient documentation submitted” (July 2010)

Two areas of high risk were identified from the demonstration project:

No reply to request/timely submission (1 additional attempt must be made prior to denial)

Incomplete or insufficient documentation to support billable services

RAC 2011 9

“For a Medicare claim to be paid, there must be sufficient documentation in the provider’s precords to verify that the services were provided to eligible beneficiaries, met Medicare coverage and billing requirements, including being reasonable and necessary, were provided at an appropriate level of care and correctly coded “ (SE1024)and correctly coded. (SE1024)

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SE1024/July No documentation or insufficient documentation submittedSE1027/S M di l i l bili i f SE1027/Sept Medical necessity vulnerabilities for inpt hospitals

SE1028/Sept DRG coding vulnerabilities for inpthospitals

SE1036/Dec Physician RAC vulnerabilities SE1037 /Jan 11 Guidance on Hospital Inpt Admission

(referencing CMS guidelines does not mandate(referencing CMS guidelines, does not mandate Interqual/Milliman, RAC judgment allowed)

SE1104/Mar 11 Correct Coding POS/Physicians Information from RAC Demo and initial findings/Live

11RAC 2011

CMS refers hospitals to Medicare Program Integrity Manual and reiterates that CMS requires contractor staff to use a

contractors are not automatically to deny claims that do not meet screening tool guidelines“ ll dd hcontractor staff to use a

screening tool as part of their medical review process of inpthospital claims. While there are several commercially available screening tools…such as Milliman, Interqual and other PROPRIETARY systems… CMS does not endorse any particular brand.

“In all cases, in addition to the screening instruments, the reviewer shall apply his/her own clinical judgment to make a medical review determination based on the documentation in the record.”

The guidance restates that the Medicare Benefit Policy Manual, Chpt 1, instructions that a

CMS repeats that contractors are not required to automatically pay a claim even if screening indicates the admission was appropriate and conversely,

Chpt 1, instructions that a physician is responsible for deciding whether the pt should be admitted as inpt.

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2-11 CMS announced a revised threshold for hospitals with $100 million in Medicare ppayments. The cap was raised to 500 per 45 day period, up from the 300 cap. AHA expressed concern over the 87 hospitals that will be impacted by this change.

It is happening. 3-17-11 Region A/DCS hospital had 498 records requestedhospital had 498 records requested.

RAC 2011 13

All RACs have begun doing (4-11) Using the automated review/data mining to identify

billing abnormalities with a high potential for improper payment.

This is followed by a request for records/complex to audit to determine if an error did occur in charge capture or claim’s submission.

EX) Tx hospital: Cataract removal can occur once per eye for the same date of service. 66984/removal with insertion of lens AND 67010-59 removal with mechanical vitrectomy) created the edit. 59 overrode edits = 2 payments.

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As of 2-14-11, modified changes Limits based on physician or non PP’s billing Tax ID p y g

# as well as the first three positions of the ZIP code where that physician/non PP is physically located.

EX: Group ABC has TIN 12345 and two physical locations in ZIP code 4567 and 4568. This group qualifies as a single entry for additional documentation requests/ADR.

Ex: Group XYZ has TIN 12345 and two physical locations in ZIP 4556 and 5566. This group would qualify as two unique entities for ADR

RAC 2011 15

ADR limits will be based on the # of individual rendering physician/non-PP reported under each

b h l dTIN/ZIP combination in the previous calendar year. Reserves the right to exceed the cap if indicated.

Group/Office Size Maximum # of requestsper /each 45 days

50 or more 50 records

25-49 40 records

RAC 2011 16

25-49 40 records

6-24 25 records

Less than 5 10 records

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Place of Service – outpt hospital vs office (SE1104 Med Learn)(S 0 ed ea )

Separate E&M leveling within the surgical/CPT bundle period

New vs Established Level of service conflicts with the hospital –

doc /inpt; hospital/OBS Office E&M leveling is not a focus of the RAC

audits …yet

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…can be the same material as the RACs. Ex. Az hospital had a ST MUE error. They osp ta ad a S U e o ey

received automated demand letters from HDI; however, they also received ‘first notice’ from WPS on the same issue. Per WPS, the site has 30 days from receipt of the WPS letter without interest to repay or be recouped on the 41stday with interestday with interest.

No published items; no limits on requests, same appeal rights.

WA state = all 1 & 2 day stays for CAH. (3-11)18RAC 2011

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DRG Description 2009 Error Rate 2010 Error pRate

313 Chest pain 55.16% 76.71%552 Medical back pain w/o

MCC70.92% 71.25%

392 Gastro & misc disorders w/o MCC

49.08% 41.93%/

641 Nutrition misc metabolic disorder w/o MCC

49.27% 48.43%

227 Cardiac defib w/o cathlab w/o MCC

20.65% 45.43%

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2-1-11 CMS Bulletin RAC for Medicaid

t d

2-16-11 CMS proposes Medicaid

t d tipostponed “Out of consideration for

State operational issues….we have determined that States will not be required to implement RAC by April , 2011 W ti i t th

payment reductions for provider-preventable conditions

Follow Medicare’s hospital acquired conditions2011. We anticipate the

final rule will be issued later this year.

Allow for additional conditions for reduction, state specific

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Medicaid integrity contractors – CMS has established a 5 year look back period with 30 y pdays to reply to requests for record (10-1-10)

RAC for Medicaid – state Medicaid units are to identify a RAC auditor by Dec 2010, implemented by April 2011. (on hold)S M di id f d i di i State Medicaid – state fraud units are auditing

Concern – avoid duplication! 3 unique groups.

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N432 = means 2 different things on the RAs.◦ Pending recoupment, should coincide with the

D d lDemand letter◦ Actual recoupment, 41 days after the demand letter

which should include interest from the 31-41st days◦ Remark codes from transmittal 659 clarify

N469 = CERT and MAC denials (Per MAC/NGS training on 3-11) Also used when postponing recoupment/Transmittal 141.

MAC accepted the payment (within 30 days) and did the recoupment on the 41st day too! (GA)

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Transmittal 659/CR 6870. “Reporting of recoupment for overpayment on the remittance advice/RA”◦ Effective date 7-1-10◦ CMS acknowledges that the current HIPAA 835 RA does not properly at both the

claim and provider level to meet the requirements of Section 935 of MMA 2003.◦ MM6870 describes the manner in which CMS will now record RAC

overpayments.◦ Step 1: Records the reversal and correction to report the new payment and

negate the original payment at the claim. Actual recoupment of funds does not occur at this step.

◦ Step 2: Reports the actual recoupment at the provider level of the 835. There is no entry at the claim level.

◦ More detail will be added to the remittance: N432 –both pending and actual t N469 t i t d b l fil d ithi 30 d / trecoupment; N469 –accts impacted by appeal filed within 30 days/recoupment

held/interest begins (Transmittal 141) Step 2: PLB reason code (FB ) forward balance. Demand letter is also sent at this time. Step 2: PLB reason code (WO) overpayment recovery. http://cms.gov/transmittals/downloads/R6590TN.pdf

RAC 2011 23

Transmittal 47, Interpretive Guidelines for Hospitals June 5, 2009 p ,www.cms.hhs.gov/transmittals/downloads/R47SOMA.pdf

“All entries in the medical record must be complete. Defined by: sufficient info to identify the pt; support the dx/condition; justify the care, treatment, and services; document the course and results of care, treatment and services and promote continuity of care among providers.

“All entries must be dated, timed and authenticated, in written or electronic format, by the person responsible for providing or evaluating the service provided.”

“All entries must be legible. Orders, progress notes, nursing notes, or other entries ….. (Also CMS covers in SE1024 MedLearn release)

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Provide a legible full signature (a readable first name and last name)P id l ibl fi t i iti l

Circle the name of the physician who wrote the prescription.U ill ibl i t Provide a legible first initial

and last name Write an illegible signature

over a typed or printed name.

Write an illegible signature on letterhead with information indicating the identity of the signer. (EX: a prescription has an illegible

Use an illegible signature accompanied by a signature log or attestation statement.

Write initials over a typed or printed name.

Write initials not over a typed or printed name, but accompanied by a signature log or attestation statement.

Neglect to sign a portion of aprescription has an illegible signature but the letterhead of the prescription lists three physician names.

Neglect to sign a portion of a handwritten note, but other entries on the same page in the same handwriting are signed.

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Heart Failure (MS DRG 291, 292, 293)Physician documentation must include the ‘type ‘ of CHF in ys c a docu e tat o ust c ude t e type o Corder to capture this diagnosis as either being a CC or a MCC condition.

Excisional Debridement (MS DRG 463, 464, 465)

Medical record documentation must support the code assignment of 86.22 and must meet the definition of g‘excisional debridement.” …involves the surgical removal or cutting away as opposed to mechanical removal, i.e. brushing, scrubbing and/or washing.

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CERT audits have continued to identify weakness in the use of Protocols.

EX) Lab urine test ordered but culture done as 2nd test due to protocol. (Noridian/Nov 2009)

EX) Without contrast but 2nd one done with contrast based on protocols.

Ensure the order is either updated or the initial order clearly states ‘with protocol as

”necessary.” YEAH – how about including the protocols that are

referenced in the record when submitting for audit?

27RAC 2011

Hybrid records present extreme challenges in identifying the skilled care/handoffs of y gintensity of service between the care areas.

EMRs tend to present the patient’s history in a ‘cookie cutter’ concept without pt specific issues.

Treatment/outcomes/results of ordered i f i d f hservices are often omitted from the

clinical/nursing record.

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1850 reporting, 1400 had activity

Medically unnecessary 57% of denials, 33%

h RAC denied $86M, up from $42 in 3rd Q

Of the $86M, 23% were appealed, 77% was not appealed

Of the 23% that was

were short stays Ave automated : $399 Ave complex : $5281

with a growing amt in medically unnecessary

Will expand the appealed, 85% were overturned in favor of the providers.

tracking of administrative burden

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#ID 10007 4/13/2010 updated on 11/2/2010 "Can the RAC do a medical necessity review on a claim that they

i i ll i d f DRG lid i ?"originally reviewed for DRG validation?" A: Beginning Nov 1, 2010, if the RAC has already requested

documentation and issued a review results letter to the provider for a DRG validation, the RAC will be allowed to re-review the claim again for medical necessity. However, if both issues are approved (DRG validation and medical necessity) prior to the request of the additional documentation, the RAC may also conduct both reviews simultaneously. Each additional ydocumentation request (ADR) is subject to the same review timeframes and counts toward the provider's ADR limit.

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#ID10239 11/2/10 "Can a RAC review a claim more than once?" A: The RAC can review a claim either

through automated or complex review more than once. The exact claim line cannot be reviewed more than once but the RAC may review different claim lines in separate reviews. In addition, the RAC may conduct areviews. In addition, the RAC may conduct a DRG validation review and then separately request documentation to complete a medical necessity review.

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Nov 11, 2010's reply from Scott Wakefield, CMS Project Officer for CGI/ Region B:

"The 60 day timeframe for a RAC to respond to The 60 day timeframe for a RAC to respond to medical records sent by a provider is a contractual requirement for the RAC National Program, therefore, it is possible that non-compliance by the RAC may result in assessment of a lower score in their annual performance appraisal. This cumulative results of this appraisal impacts CMS's determination of whether to extend the incumbent RAC's contract for an additional year. I recommend you contact the RAC directly and inquire about follow up with the remaining records Iinquire about follow up with the remaining records. I have copied certain CGI federal staff on this email and will request that they follow up with me."

No direct penalty, no auto closing/approved of case.

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Charged to the provider if demand amt is not paid within 30 days of the letter. 31-41st days of interest, auto recouped on 41st day.

Charged to the provider if an appeal is filed within 30 days (normal is 120) to stop the recoupment.

Paid to the provider if the money was recouped on the 41st day, appeal filed and overturned.y, pp

No interest is paid if the money is given back voluntarily, even if over turned on appeal.

Interest is each 30 days, not compounded. 11%

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Document your waste. Recouped for charging 60 U when only 50 was g g ydocumented. Used single use vial, but no wastage was documented. (pharmacy? Nursing? Eff 6-10)

Do not use default CPT codes. 99218/initial day OBS has a MUE of 1. However, some hospitals are using for OBS hrs in FL 44 Ifhospitals are using for OBS hrs in FL 44. If not required to use G code, leave blank.

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MAC/NGS has an LCD (L25820) with document expectations for drugs and biologicals.

“The medical record must include the following information: The medical record must include the following information:◦ The name of the drug or biological administered◦ The routing of the administration◦ The dosage (e.g. mgs, mcgs, cc’s or ICUs)◦ The duration of the administration◦ When a portion of the drug or biological is discarded, the medical record

must clearly document the amt administered and the amount wasted or discarded.”

Policies on how this will be done – as other payers may not acknowledge the billing of wastage.

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19 inpts ADRs in 6 week period All 1 day or very short stay on inpt surgeriesday o e y s o t stay o pt su ge es

Acute appy- day

CVA/TIA-1 day

Hypokalemia/Acute Renalfailure – 2 days

Total shoulder –1 day

HypotensivePt/readmit

GI bleed-2 days

Below knee amputation-1day

BreastReduction-1 day

Carbon monoxide-1

Pneumonia-2 days

Seizures/PNA-expired-1day

Hemo cathplacement-1

Total knee replacements – 2 days

Obstructivehepatisis-transferred

Non-unionmalleolus(surgery) -1 day

Panyctopenia – 1 day (?comfort care)

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Closely watch the RAC’s portal. Historical information disappears! Monitor receipt of

d / l f drecords/completeness of records. Discussion period has no mandated response

time from the RAC. Do not wait to start appeal activity while you are waiting for the RAC to reply/defend their position.

12 cents per page for copying if mailed –except critical access. (CD w/23 records, $4.95) PLUS Look at the CD closely before submitting

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Medically unlikely edits have resulted in charge capture errors. Many MUEs are g p yunknown to the providers.

Examples:◦ 4 ST/92507 treated as per 15 instead of per

encounter. Only 1 is allowed◦ 4 EKG/93005 MUE is 3 in a given 24 hr outpt day.

Would have to appeal that the 4th one was medicallyWould have to appeal that the 4 one was medically necessary to the uniqueness of the pt’s needs.

39RAC 2011

No auto crossovers/Medigap for pt portion. All pt portions are due to the pt or their supplementsupplement.

MAC can override the DRG that the RAC assigned. (Connolly/Cahaba) Which one is appealed?

Time gap between then the complex letter was mailed by the RAC and the receipt. Date of the letter begins the 45 day countDate of the letter begins the 45 day count with 10 mail days.

Big delays between RESULTS and DEMAND letters

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Underpayments are occurring too. EX) IA hospital billed transfer DRG – pt was to

have had HH or SNF care post inpt. Facility was paid a per diem vs DRG.RAC identified the underpayment as there were no claims from HH or SNF for the post care. Repaid full DRG for 7 accounts, $13,000.

Better practice idea: D/C planning verifies in the 3 day hold that the pt had above services. Revised discharge disposition.

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Underpayment: MAC had mis-paid the multiple CPTs on an outpt APC claim. (71 accts/WA)

Rescinded after records sent! All 4 RACs are now doing Rescinded after records sent! All 4 RACs are now doing this with no explanation for why! Huge cost to providers

CGI is auditing Oxaliplatin/unit errors PLUS documentation of wastage (with or w/o JW)

50 bed Ark hospital lost 1 ‘no inpt order’ in a Connolly audit. “ Per CMS publication 100-02, Chpt 1, section 10 and CMS pub 100-4 Chpt 3 section 10 & 40 2 2 thisand CMS pub 100-4 Chpt 3, section 10 & 40.2.2, this claim cannot be billed as an inpt hospital stay because documentation does not contain the necessary physician’s order. This results in a retraction of $14,592. “ Appealing

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Why us? There does not appear to be any patterns to the requests. They are one of 3 hospitals in the area. Only one to be hit with audits.hit with audits.

Max # of records per 45 days: 48. Have had 143 in last 12 mon High DRG: 69/Transient Ischemia, 312/syncope & collapse,

101/seizures w/o MCC Complex:◦ Sept, 2010 – 1st medically necessary audits. 48 had both DRG and MN. All 48

had 0-2 day LOS◦ Appears Connolly is targeting the 2nd diagnosis that make up the CC or MCC

RAC Target DRGs: 981/982/983 Extensive & non extensive OR procedures◦ RAC Target DRGs: 981/982/983 Extensive & non-extensive OR procedures unrelated to principle Dx. Also 330/sm & lg bowel procedures237/major cardiovascular w/MCC; 242/permanent cardiac pacemaker implant w/MCC.

4 highest MDCs: Respiratory, circulatory, digestive and Musculoskeletal & connective

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Automated◦ MUEs – lab/80053 comprehensive metabolic profile &

83880 BNP83880 BNP◦ CPT 62311/lumbar injection. MUE only looks for the correct

modifier w/no considerations for distinct locations.

QUIRKY:◦ MAC assigns the overpayment amt for the demand letter. 1

demand letter where the demand was more than submitted.◦ On at least 2 claims, the MAC approved a RAC denial and gave the

RAC i i t d t d d l tt Th RAC f il d t dRAC permission to send out a demand letter. The RAC failed to do so. The MAC assumed we had not responded to a letter so they went ahead and recouped the payment.

◦ NUTS!

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If a provider performs a self audit, how should they notify the RAC?

A: If a provider does a self audit and identifies improper a p o de does a se aud t a d de t es p opepayment, the provider should report the improper payments to the appropriate MAC, FI or carrier. The exact information necessary for the self referral can be determined by contacting your Medicare claims processing contractor.

There are two types of self audits: 1) Commonly called a voluntary refund and is claim based. If the required claim information is included along with the amt of the improper payment, the claim will be adjusted. The RAC will be aware of the adjustment, but the refund does not preclude future review. 2) Involves extrapolation. If extrapolation ispreclude future review. 2) Involves extrapolation. If extrapolation is used, the claim processing contractor will review the case file to determine if it is acceptable. The MAC can accept or deny the extrapolation for the issue identified by the provider. If the claim MAC accepts the extrapolation, these claims will be excluded from the RAC review.

RAC 2011 45

Initial claim submission of Part B on a Part A claim is allowed. No Obs, no surgery, no , g y,anesthesia, no recovery. Ancillary only.

Rebilling of a denied inpt claim within the timely rebilling requirements is a Part B on a Part A claim. Bill type 12x. Ancillary only.

HOPE: AHA continues to champion trying to CMS ll bill 131/ lget CMS to allow bill type 131/regular outpt

for a rebilled denied claim.

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These revenue codes/department charges are billable on a Part B claim of a denied Part A service. 12x (Benefit Policy Manual, Chpt 6, section 10)

27x/supplies; 30x/lab;32x/imaging; 331 & 335/chemo; 333/Radiation therapy; 34x/nuc med; 35x/CT; 379/anesthesia; 401/dx mammo; 402/ultrasound;403/screening mammo; 404/PET; 42x/PT; 43x/OT; 44x/ST; 46x/pulmonary; 48x/cardio, cath lab, cardiac stress test; 540-45/ambulance; 61x/MRI;634/Epo under 10,000 U; 635/Epo over 10,000 W;636/pharmacy;730 1/EKG & ECG tele;732/tele;739/EKGW;636/pharmacy;730-1/EKG & ECG tele;732/tele;739/EKG cardio lab;74x/EEG;77x/Vaccination adm;790/litho;920/other dx services; 921/vascular lab; 922/EMG;923/pap smear;929/invitro fertilization; 985/non-invasive physician. NO Surgery!

RAC 2011 47

Can I rebill or must I file an appeal? Call with CMS/HDI/WPS J5, a MAC 7-8-10

If RAC has identified a MUE due to a charge If RAC has identified a MUE due to a charge capture error and there was an accurate CPT that should have been used, an appeal & corrected UB must be filed to get the money for the corrected CPT.

If the facility did data mining and found that the same issue had occurred on other claims, a corrected claim should be submittedcorrected claim should be submitted.

Discuss with the MAC prior to either to ensure it is done correctly.

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If an inpt/outpt is denied and the facility determines a misunderstanding of a Medicare

l ti d t t th t CPTregulation occurred, to get the correct CPT code/corrected amt, the facility must appeal. Additionally, the RAC team should immediately discuss the need to continue to data mine similar issues.◦ Internal cost as manual rebill.◦ Only ancillary services can be rebilled

Pt h d f d f i t d d t bl ill t t i◦ Pt had refund for inpt deductable; now will owe outpt coinsurance.◦ Perception to public◦ Real C A S H◦ Track and trend any recoupments with rebills separate from recoupments with

100% absorbed losses◦ Timeline for rebills must be followed

RAC 2011 49

• If the inpt is denied, the pt (and Medigap supplements) will be informed they don’t owe the inpt deductible. Ref nd to pt and/or s pplement or a to reco pmentRefund to pt and/or supplement or auto recoupment.

• If the facility determines they would like to do a corrected claim submission once a decision is made not to appeal – the pt will receive notice they owe a new outpt deductible/coinsurance.

• If the outpt claim is denied payment, the pt will be informed they don’t owe the outpt portion.y p p

• HINT: Develop scripts for the PFS staff to explain.• NOTE –all activity/recoupments can go back 3 years

beginning with 10-1-07 PD dates rolling forward.

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Dear pt As part of ABC hospital’s commitment to compliance, we are

continuously auditing to ensure accuracy and adherence tocontinuously auditing to ensure accuracy and adherence to the Medicare regulations.

On (date), Medicare and ABC hospital had a dispute regarding your (type of service). Medicare has determined to take back the payment and therefore, we will be refunding your payment of $ (or indicate if the supplemental insurance will be refunded.)

If you have any questions, please call our Medicare specialist, S J t 1 800 h h it l W l i fSusan Jones, at 1 -800-happy hospital. We apologize for any confusion this may have caused.

Thank you for allowing ABC hospital to serve your health care needs.

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New issue: Inpt Admissions without a Physician’s Inpt Admit Order.y p

Description: Admissions to the inpt setting require a physician’s order in order to qualify and be paid as an inpt stay.

Inpt hospital 10-01-07 open Reference info: CMS pub 100-02, Chpt 1, p p

section 10 and pub 100-4 Chpt 4, section 10 and 40.2.2

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Addition documentation letter received read:“Good Cause for Issue: Chronic Obstructive Pulmonary Good Cause for Issue: Chronic Obstructive Pulmonary Disease DRG 88 MS-DRG 190, 191 (Medical Necessity Review and MS-DRG Validation). During the course of the DRG validation, the RAC will also review the record for inpt admission order.

The documentation is being requested because COPD is one of CMS’s top volume DRGs. Therefore, DRG 88, currently MS-DRG 190 and 191 was selected to determine if theMS DRG 190 and 191 was selected to determine if the principle and secondary diagnoses were assigned inappropriately resulting in overpayments to the hospitals. An analysis of your billing data indicates that a potential aberrant billing practice may exist for these MS-DRGs.”

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Dec 9, 2010 letter from Region A/DCS outlining rationale for why they were requesting medical records for numerous DRGs They also gave a great outline offor numerous DRGs. They also gave a great outline of inpt vs obs.

“Inpt care rather than OBS is required only if the pt’s medical condition, safety or health would be significantly and directly threatened if care was provided in a less intensive setting. A patient must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be furnished safely and effectively only on an inpt basis.”effectively only on an inpt basis.

When auditing for ‘what does severity and intensity look like- look for the above issues to be addressed in the physicain admit note/order and the nursing bedside documentation.

55RAC 2011

1st MN request, 90 records, DX listed below for the 6 MN new issues

Had DRG MN and inpt accuracy listed on all Had DRG, MN and inpt accuracy listed on allCOPD Cardiac

ArrhythmiaExcisionaldebridement

Heart failure and shock

Renal failure Extensive OR procedure unrelated to principal Dx

Disease/disorderof the respiratory system

Kidney & UTI

Espohagitis/gastronenteritis

Aneurysm repair Coronary bypass w/PTCA

Tracheostomy

Perc Cardiovascprocedures w/stent

GI Disorders Other circulatorysystem dx

Other vascular dx

Syncope and collapse

Red blood cell disorders

Atheroscleroriswith MCC

Nervous systemdisorders

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Rural Critical Access hospital. Ave Census 2 HDI “short stay change notification”. “After our

review it is our determination that the claimsreview, it is our determination that the claims listed should have been outpt OBS vs inpt.” 8-18-10

Direct admit from a clinic. HDI findings: “Pt chief complaint was hypoxia. The pt presented to

ED for acute bronchitis, severe COPD – admitted as an inpt. Past medical hx and the pre-existing conditions are stable. The medical records did not document pre-are stable. The medical records did not document preexisting medical conditions or extenuating circumstances that make the acute inpt admission medically necessary. The med record document services that could be provided as an outpt service.”

57RAC 2011

“RAC will review documentation to validate the medical necessity of short stay, uncomplicated admissions of MS DRG (XXX). Medicare only pays for inpatient hospital services that areMedicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly.”“RACs will also review documentation for DRG Validation requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim matches both the attending physicianhospital on its claim, matches both the attending physician description and the information contained in the beneficiary’s medical record. Reviewers will validate for MS-DRG, principal diagnosis, secondary diagnoses and procedures affecting or potential affecting the DRG.” (Aug 2010)

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CGI has started complex requests for OUTPT services. So far all outpt have been automated -most MUE problems. (Sept 2010)2010)

Basic Radiation Dosimetry Calculation - Outpt- CPT 77300 Comparison will be made in regards to units of Dosimetry

calculations reported in the medical record versus those units of dosimetry calculation reported on the claim, to establish whether a difference inn reported units compared to those documented resulted in an overpayment for CPT 77300.

HDI has issued “minor surgery and other treatment billed as an i t t ” Cl i bill d f i th t t tinpt stay” Claims billed for minor surgery or other treatment are identified for medical review based on risk of inpt improper payment.” (Oct 2010)

Involve surgery scheduling/surgery director and UR to review all cases.

59RAC 2011

HDI and CGI have started sending their ‘New Issue Validation’ sample letters.p

Statement of Work allows sampling of up to 10 claims (in addition the 45 day limit) to prove a vulnerability with a new issue. Results will be issued on the findings with data submitted to the New Issue Board/CMS.HOT Sh h d i l HOT: Share what was requested so potential new items are know; preventive work.

EX) Readmission within 30 days for AMS.

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June, 2010 Connolly posted new issues relative to drug /J code accuracy. Tying the J code and the

l l hunits/multiplier on the UB. Paclitaxel Cetuximab Paclitaxel protein –bound particles Tenectplase Pamidronate disodium Pamidronate disodium Adenosine Zoledronic acid (reclast) 1 mg

61RAC 2011

A) When validating all information prior to submission, be sure to specifically address any issues outlined in the letter. This applies to appeal or discussion periods or any communication. Simply stating that our patient was very sick -although accurate - the audit is auditingour patient was very sick although accurate the audit is auditing billed services (as reflected on the UB and 1500 forms) are accurately reflected in the medical record.

B) Do you have a clinical documentation improvement program? EXPAND It beyond typical physician documentation to clarify DRG issues to SEVERITY of illness/docs and INTENSITY of services /nursing. Grow the documentation to support the level of care billed..

C) Track and trend your own vulnerabilities thru the validation prior to submission process. The opportunities are endless for our records to be improved -including revising EMR documentation Patterns of risk areimproved -including revising EMR documentation. Patterns of risk are excellent tools for ongoing education , process changes, form development and overall cohesive pt care. Charting by exception is the worst type of charting to show intensity of care. Tell the pt's story and outline the interventions, results, handoffs, etc that occurred.

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D) ALWAYS print off the EMR (even if you have an release of information vendor, especially if you have a hydrid record ) and closely audit the handoffs between the departments - closelyclosely audit the handoffs between the departments closely looking for intensity of care, clarity in interventions (what we did about results, tele strips) and how the pt's condition continued to warrant an acute level of care.

E) Major focus on nursing's canned documentation with EMRs.. Number the pages; create a cover letter that CLEARLY shows the doc's order for inpt with WHY he wanted them in an acute care setting with a defined course of treatment plus highlights of test results, intensity of the condition, etc. The l k f thi t f lid ti il lt i f t dlack of this type of validation can easily result in a fragmented record with very difficult severity and intensity of care identified. (HOT SPOT: ER = paper; floor nursing = electronic. How many admits come thru the ER? Huge area of audit and focused documentation improvement.)

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Summary: Review & Collection ProcessAutomated Review

RAC makes a claim

determination

2

5

Carrier/ FI/MAC issues

3

New Automated

Review Issue

Posted to RAC’s

website

1

The Collection Process

From Cmdr Casey, RN, CMS

Complex Review

Day 41

Carrier/FI/MAC

recoups by offset

5

New Complex Review Issue

6

Provider submits medical

8 RAC clinician reviews medical records;

9

issues RemittanceAdvice (RA) to provider

N432: “Adjustment based on a Recovery

Audit”

• Recoupment will NOT occur if:

provider has paid in f ll

64

If nofindingsSTOP

• Provider has 45 + 10 calendar days to respond

• Providers may request an extension

• Claim is denied if no response

• RAC has 60 calendar days from receipt of medical record to send the Review Results Letter

Posted to RAC’s

Website

medical records

;

makes a claim determination

full; orprovider

filed an appeal BYday 30

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33

Which option should I use?

Discussion Period

Rebuttal Redetermination

The discussion A rebuttal should be AThe discussionperiod offers the opportunity to provide additional information to the RAC to indicate why recoupment

A rebuttal should be submitted only on rare occasions of extreme financial hardship. The rebuttal process allows the provider the opportunity to provide a statement and accompanying evidence indicating why the overpayment

A redeterminationis the first level of appeal. A provider may request a redetermination when they are dissatisfied with p

should be initiated. It also offers the RAC opportunity to explain the rationale for the overpayment decision.

why the overpayment would cause extreme financial hardship.A rebuttal is not intended to review supporting medical documentation. A rebuttal should not duplicate the redetermination process.

the overpayment decision. A redetermination must be submitted within 30 days to prevent offset on the 41st day.RAC 2011 65

Discussion period

Rebuttal Redetermination

Who do I RAC Contractor/MAC Contractor/MACWho do I Contract

RAC Contractor/MAC Contractor/MAC

Timeframe Day 1-40 Day 1-15 Day 1-120; must be submitted within 120 days of demand letter. To prevent offset on day 41; file within 30 days but i t t illinterest will accrue (Transmittal 141)

Timeframe begins Automated review-upondemand letter:Complex-upon results letter

Date of demand letter

Upon receipt of demand letter

Timeframe ends Day 40 (offset begins on day 41)

Day 15 Day 120RAC 2011 66

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June 26, 2009/CMS Website CMS reversed earlier decision to AUTO C S e e sed ea e dec s o to U O

recoupment SNF payment if the hospital is denied/recouped its 3 day qualifying stay.

If the hospital is recouped for any activity, Part B/physician will be evaluated, but not auto recouped.

Will look but not auto recoup in both.

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• Region A (DCS)– www.dcsrac.com– info@dcsrac.com– 1-866-201-0580– CMS RAC Contact: Ebony.Brandon@CMS.hhs.govy g

• Region B (CGI)– http://racb.cgi.com– racb@cgi.com– 1-877-316-7222– CMS RAC Contact: Scott.Wakefield@CMS.hhs.gov

• Region C (Connolly)– www.connollyhealthcare.com/RAC– RACinfo@connollyhealthcare.com– 1-866-360-2507– CMS RAC Contact: Amy.Reese@CMS.hhs.gov

• Region D (HDI)– http://racinfo.healthdatainsights.com– racinfor@emailhdi.com– 1-866-590-5598 Part A1 866 590 5598 Part A– 1-866-376-2319 Part B– CMS RAC Contact: brian.elza@CMS.hhs.gov

• CMS assigns a project officer to each RAC. Use if abuse of the SOW or other issues are occurring.

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• New issues will be posted, RAC specific• There is a CMS/project officer assigned to each RAC

578 RAC d f i 498 d• 578 RAC requested for new issues; 498 approved• Some are being added/some are being taken off.

• Region A-DCS Info@dcsrac.com 866 201 0580• Region B-CGI RACB@cgi.com 877 316 7222• Region C-Connolly

www connollyhealthcare com/RAC; RACwww.connollyhealthcare.com/RAC; RAC info@connollyhealthcare.com 8663602507

• Region D-HDI racinfo@emailhdi.com 866590 5598

RAC 2011 69

Audit Results and Better Practice Ideas

To Reduce Risk

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“HDI has signed a 5 year license with Milliman Care Guidelines. HCI will use the care guidelines content and software to review Medicare claims.

HDI will use the annually updated evidence based care guidelines products.

The Care Guidelines promote healthcare quality by providing clinical guidelines based on the best available clinical evidence.”

CMS does not mandate or endorse any specific guidelines or criteria for utilization review.”

Feb 25, 2009 “Evidence-based care guidelines will be used to combat waste in Medicare program.”

RAC 2011 71

An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as inpatient with the expectation that he or she will remain at leastinpatient with the expectation that he or she will remain at least overnight and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight.”“However, the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient's medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital's by-laws and admissions policies, and the relative appropriateness of treatment in each setting. Factors to be pp p gconsidered when making the decision to admit include such things as:– The severity of the signs and symptoms exhibited by the patient;

– The medical predictability of something adverse happening to the patient…”

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…direct pt care …thru Determining correct statusg Clarifying order of the status ◦ Examples of weak orders: Admit to Dr Joe, Admit to tele,

Transfer to the floor, admit to 23:59, admit to medical service, admit to FIT. None clearly define : Admit to inpt status and why –add (intent of the order)

Directing the clinical team as to the intensity of services that need provided when the pt ‘hits theservices that need provided when the pt hits the bed’ as well as thru the course of treatment.

RAC 2011 73

Many facilities are using outside physician advisors or are growing their own advisors –many times the UR physician.

Ensure that any 2nd opinion by a non-treating provider is ‘validated’ and used for directing care by the attending/admitting. Otherwise it is just another non-treating opinion. Additionally, look for educational p y,opportunities thru patterns --dx, documentation, doctor.

Double check with the QIO for their opinion during audit.

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Trailblazer/MAC Jurisdiction 4, 8-30-10 “Inappropriate Hospital Admission vs Outpt Observation”M di i h h i d i i b i h Medicare requirements that the inpt admission begins when

the admission order is written. Additionally, all physician orders must have a date and a legible signature.

Physician’s decision to treat the pt as an outpt or inpt are reflected in the physician’s orders. The pt’s condition, history and current dx test results, along with the physician’s medical judgment, availability of treatment modalities and hospital admission policies should be considered whenhospital admission policies should be considered when making a decision to provide inpt level of care. If a physician determines additional information is making a medical decision for inpt admission, the physician may elect to place in OBS outpt status.

75RAC 2011

Scenario 1 An inpt claim is submitted for medical review◦ The claim is without a written and signed physician order for admissionThe claim is without a written and signed physician order for admission◦ The documentation is without an admit note describing the reason for

admission to an inpt level of care/LOC◦ The services rendered could have been rendered in an outpt setting◦ The screening tool indicates the intensity of services and the severity of

illness of the pt’s condition as documented did not support the medical necessity for inpt LOC

◦ Medical review decision: Denied because documentation does not support the medical necessity for an acute level of care

◦ IF THE PATIENT’S CONDITION REQUIRES INPT ADMISSION, the physician d d i d i i d i hneeds to document an inpt admission order with a progress note

describing the medical decision for the inpt admission and the intended treatment plan to address the patient’s condition.

◦ Internet Only Medicare Manual (IOM) Pub 100-04, Medicare Claims Processing Manual; chapter 1, section 50.3; chapter 3, section 40.2.2.k

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Variance rate: 40% Common findings: ◦ UR/physician dialogue may indicate inpt, but the

documentation in the admission order (or subsequent physician documentation) is not sufficient to address the severity of the pt’s condition for today’s condition that warrants an inpt acute level of care.

◦ “Meets or doesn’t meet Interqual” does not make an inpt. Medicare’s definition is not well known.

◦ Weakness in EMRs that do not address the ‘uniqueness’ of qthe pt’s care and intensity of the service that is being performed. (Nursing documentation- no narrative to support electronic-no ability to expand on the uniqueness of the pt’s story.)

RAC 2011 77

Problematic diagnoses and other risk areas:◦ Rule out – anything! If a physician is not clear as to the

reason for admit/undetermined dx or course of treatmentreason for admit/undetermined dx or course of treatment, place in OBS, aggressively work up the pt and rule in= inpt; rule out= discharge safely. (Exceptions do exist)

◦ Using a non-treating physician to confirm inpt status does not replace or supplement the attending/treating physician’s documentation.

◦ Conversations to support “admitting to inpt” is rarely actually documented in the record.H&P d D/C i t i t tl t◦ H&Ps and D/C summaries are not consistently present.

◦ Normal OUTPT Surgeries being ordered as inpt surgeries…not on the inpt only list. UR needs to work closely with surgery scheduling.

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40

Definite misunderstanding of what OBS is. Viewed as a time frame rather than a pt’s p

condition. (Miracle 23 hr cures = discharge or Monday am quarterbacking to ‘fix weekend.”)

Billable hrs vs hrs in a bed Audit three types of OBS:◦ ER to OBS – saw provider onsite◦ Post procedure to recovery to OBS◦ Direct from a provider or SNF to a bedHighmark/MAC , new inpt/OBS

www.highmarkmedicareservices.com/bulletins/parta/newsrooms/news09302010

RAC 2011 79

• Variance rate two fold:– To be an inpt 40%– To remain an inpt 60%

• Audit focus:– Medically appropriate to be an inpt– Medically appropriate to remain an inpt for all 3

days.– Severity of illness/1st day; intensity of service/all 3Severity of illness/1 day; intensity of service/all 3

midnights.– Common weakness: Social admits= TOUGH

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• When submitting a request for an appeal, you have different options.S b it i iti i f Wh tili i th f• Submit in writing or via fax. When utilizing the fax, there is no need to follow up with a hard copy of the documentation.

• Submit your request only one time, utilizing only one method.

• Duplicate submissions or following up with hardcopy may delay your appeal.py y y y pp

• If you are bringing attention to a specific item you are faxing, please circle or indicate by asterisk, as highlights do not appear when the fax Is received.

Aug 20, 2010

81RAC 2011

Begin charge capture/charge reconciliation audits. Department head ownership!p p

Begin ongoing reimbursement education with audits of billed services against documentation.

Focus on identified weaknesses from benchmark audits, RAC automated results

d l i i h i iand complex reviews – with corrective action plans.

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Joint audits. Physicians and providers audit the i OBS d 3 d SNF lif i linpt, OBS and 3 day SNF qualifying stay to learn together.

Education on Pt Status. Focus on the ER to address the majority of the after hours ‘problem’ admits.

Identify physician champions. Patterns can be identified with education to help prevent repeat

blproblems. Create pre-printed order forms/documentation

forms. Allows for a standard format for all caregivers.

83RAC 2011

• Region A (DCS)– www.dcsrac.com– info@dcsrac.com– 1-866-201-0580

CMS RAC Contact: Ebony Brandon@CMS hhs gov– CMS RAC Contact: Ebony.Brandon@CMS.hhs.gov• Region B (CGI)

– http://racb.cgi.com– racb@cgi.com– 1-877-316-7222– CMS RAC Contact: Scott.Wakefield@CMS.hhs.gov

• Region C (Connolly)– www.connollyhealthcare.com/RAC– RACinfo@connollyhealthcare.com– 1-866-360-2507– CMS RAC Contact: Amy.Reese@CMS.hhs.gov

• Region D (HDI)– http://racinfo.healthdatainsights.com– racinfor@emailhdi.com– 1-866-590-5598 Part A– 1-866-376-2319 Part B– CMS RAC Contact: Brian. Elza@CMS.hhs.gov

• CMS assigns a project officer to each RAC. Use if abuse of the SOW or other issues are occurring.

4/28/2011

43

• New issues will be posted, RAC specific• There is a CMS/project officer assigned to each RAC

578 RAC d f i 498 d• 578 RAC requested for new issues; 498 approved• Some are being added/some are being taken off.

• Region A-DCS Info@dcsrac.com 866 201 0580• Region B-CGI RACB@cgi.com 877 316 7222• Region C-Connolly

www connollyhealthcare com/RAC; RACwww.connollyhealthcare.com/RAC; RAC info@connollyhealthcare.com 8663602507

• Region D-HDI racinfo@emailhdi.com 866590 5598

RAC 2011 85

Day Egusquiza, Presidenty g qAR Systems, IncBox 2521Twin Falls, Id 83303208 423 9036daylee1@mindspring.com

Thanks for joining us!Thanks for joining us!Free info line available.Plus our training website: www.healthcare-

seminar.com

RAC 2011 86