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Conduct reviews with Recovery Auditor denials in mind

JustCoding News: Inpatient, April 23, 2014

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by Trey La Charité, MD
Reducing mistakes and eliminating fraud are the dual goals in today’s claims auditing environment. While these goals are admirable, the aggressive strategy typically executed by Recovery Auditors (RA) and other auditing agencies to achieve those goals is fundamentally flawed.
The reality is that our healthcare facilities are subjected to a myriad of “Recovery Raiders” that scrutinize everything—from how many units of a drug were billed to whether or not a patient actually needed to be admitted to the hospital. Whether contracted by the federal or state government or employed by the private insurance companies, these entities lack appropriate oversight and accountability.
Coding is hard, our coding system is complex, and yes, we humans make coding mistakes. However, honest coding errors do not warrant the brazen tactics employed by auditors in an effort to grow their coffers at the expense of our patients’ care.
The unfortunate reality is that most facilities do not have the resources necessary to lobby Washington to correct the current situation. Being pragmatists, we must do the best we can with the resources we have.
One of the main goals of a CDI program is to help audit-proof a facility’s medical records. To achieve this objective, every denial must be turned into a learning opportunity.
Over the years, my facility experienced all varieties of denials, ranging from perfectly appropriate (i.e., we coded it wrong!) to egregious attempts to paint our facility as committing fraud. The observations that follow offer strategies to better protect your facility from auditors’ denial attempts.
Defend single CC/MCC targets
An auditor’s sole reason for issuing denials is to recoup a portion of a facility’s previously received reimbursements.
For example, if you have submitted a claim that has four MCCs, the auditors are not going to waste time verifying whether or not the clinical criteria for acute respiratory failure were met during that admission. Auditors are looking for the most vulnerable charts they can find and exploit—records that have only one CC or only one MCC listed on the coding summary form, for example.
Unfortunately, auditors can easily discern which charts fall into these categories from the UB-04 form. If the auditor can disprove, deny, or disallow that solitary CC or MCC by some mechanism, the MS-DRG would be downgraded to a lower-weighted submission, resulting in an auditor’s favorite statement: “An overpayment has been noted.” Therefore, a submission with only one documented CC or MCC needs to be absolutely bulletproof.
Although auditors do not issue denials to help you improve your documentation and coding practices, that doesn’t mean you cannot learn from their actions, adapt your efforts, and audit-proof your records. The following is a list of common Recovery Auditor tactics employed to remove a single CC or single MCC from our records:
Challenging whether a diagnosis meets the accepted criteria to be considered a legitimate, secondary diagnosis.
A valid secondary diagnosis must meet one of the five following standards:
1. The condition required clinical evaluation
2. The condition required therapeutic treatment
3. The condition required diagnostic workup
4. The condition extended the patient’s length of stay
5. The condition increased the level of nursing care and/or monitoring that the patient required
If the auditor can prove that a given diagnosis did not touch on one of those five standards, they will deny your claim, and should you choose to appeal that denial, you will lose.
Challenging your provider’s definition of a clinical diagnosis based on criteria favorable to the auditor’s position.
For example, some auditors have attempted to disallow the diagnosis of acute renal failure based on the outdated RIFLE criteria, completely ignoring the more recently accepted definition of acute renal failure put forth by the Acute Kidney Injury Network. When your facility collectively sets clinical standards that align with industry best practice, you can use these standards to defend your claim.
Do not blindly accept an auditor’s stance.
Challenging the coding of a given diagnosis if the auditor believes there was conflicting or contradictory documentation between providers regarding that diagnosis.
For example, Provider 1 called something “X,” but Provider 2 called the same thing “Q.” If you coded X instead of Q (and removing X would result in an MS-DRG downgrade), the auditor will deny the claim for X and state that you should have queried prior to claim submission to clear up the “conflicting or contradictory documentation.”
Challenging your medical staff’s clinical judgment.
An auditor once stated they did not believe a patient had an acute myocardial infarction, as diagnosed by one of my board-certified cardiologists. The auditor’s position was that the patient’s elevated troponin levels could have been due to a number of other disease processes and not just the documented acute myocardial infarction.
The auditor ignored the fact that my cardiologist had dictated in his consultation that “this patient’s elevated troponins most likely represent a Type II acute myocardial infarction.” The auditor further brushed aside the fact that the cardiologist carried the diagnosis throughout the rest of the chart and listed it in the discharge summary. These types of situations should be appealed.
Challenging your coder’s selection of principal diagnosis.
As you are aware, changing a given principal diagnosis may alter which additional documented diagnoses qualify as a CC or an MCC. I’ll say it again: Coding is hard, and poor documentation by providers makes it harder. However, due diligence must be paid to this issue so that the final choice of principal diagnosis is as accurate as possible.
Remember, according to the Uniform Hospital Discharge Data Set (UHDDS) Guidelines, the principal diagnosis is the condition after study that occasioned the admission. The principal diagnosis isn’t simply the reason that the patient came to the hospital, but the condition the physician determines to be the reason for that person’s admission and the required level of treatment.
Identify additional audit challenges
In addition to challenging a solitary CC or MCC, we have seen other strategies auditors use to issue denials, including the following scenarios:
Challenging coder selection for procedures.
We have noticed auditors have a particular penchant to deny anything considered a valid OR procedure, such as excisional debridements and fiberoptic bronchoscopies. As valid OR procedures have a huge financial impact on any given submission, auditors find these to be irresistible targets.
Challenging code selection through blatant guideline misinterpretation and manipulation.
When an auditor quotes a citation from the AHA’s Coding Clinic or the Official Guidelines for Coding and Reporting, be sure to reread the specific guideline in its entirety. We have seen examples of auditors who take only a portion of a specific guideline and use the guidance out of context. If you do not take the time to review the statements against the actual guidelines, it can seem as if the auditor has a legitimate point.
Develop post-discharge query processes
Ideally, all of the above documentation questions would be resolved prior to the patient’s discharge. However, most facilities simply do not have enough CDI personnel required to accomplish this lofty goal. Therefore, a strong post-discharge query process is an absolute imperative.
In our facility, we convert any unanswered concurrent queries issued by our CDI specialists to post-discharge queries. Additionally, any new documentation discrepancies or diagnosis validation issues discovered by our coders are addressed with the involved providers as post-discharge queries.
All post-discharge queries must be answered prior to final claim submission. Our philosophy is quite simple—the more eyes that review a given chart, the higher the probability a potential liability will be discovered and addressed prior to auditor review.
While this level of dedication is necessary in today’s auditing environment, one must be prepared for the increased volume of queries it generates. Provider frustration due to increased post-discharge query volumes and our internal difficulties keeping track of those post-discharge queries became issues we had to address.
In response, we created a new position within our CDI program: a CDI clerk. This person’s responsibilities include post-discharge query distribution, query tracking, and query collection upon provider completion. Our providers are now more comfortable with the post-discharge query process, as they have a consistent and familiar representative available to answer their questions. Additionally, we now know where every query is in the hospital at any given moment.
In summary, RAs' efforts are a painful reality for all healthcare facilities. Fighting every incorrect and inappropriate denial is a necessity to preserve your institution’s bottom line and facilitate your patient care mission. In my opinion, the best defense against the RAs is a good offense, as the adage goes.
Therefore, my advice is to ensure that the auditors are never able to issue a denial in the first place.
My ultimate hope is that our providers learn that the need for queries, whether concurrent or post-discharge, completely depends on their documentation habits at the time they actually take care of the patient.
Editor’s note: La Charité is a hospitalist with the University of Tennessee Hospitalists at the University of Tennessee Medical Center at Knoxville (UTMCK) and an ACDIS advisory board member. His comments do not necessarily reflect those of UTMCK or ACDIS. Contact him at clacha­ri@utmck.edu.


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