learning objectives how to beat the rac · how to beat the rac mark l. friedman, md, facep, facp...

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How to Beat the RAC

Mark L. Friedman, MD, FACEP, FACPPresidentMedical Directions Corp.Westport, Conn.

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Learning Objectives

• Describe the RAC program and who represent its auditors

• Apply lessons learned to RAC denials case scenarios

• Develop appropriate CDI review techniques and physician education strategies to avoid denials

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• Know your adversary• What is their motivation?• What are they thinking?• What will they do next?

How to Beat the RAC

• What will they do next?• Good documentation• Good coding• Credible appeals• Learn from experience/feedback loops

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What CMS Sees

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CMS Error Rate

• FY 2007 CMS paid in error $10.8 billion for Medicare fee-for-service claims*

• Medicare paid out $421 billion in 2007*• CMS reported this as a 3.9% error rate*CMS reported this as a 3.9% error rate• Correct coding is worth its weight in GOLD

* http://www.dhhs.gov/afr/information/improper/ipiar-iii.html* http://www.hhs.gov/afr/information/challenges/topoig-02.html

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The Billion-Dollar Problem

• Lost revenue ($2.4 BILLION 2012)• Wasted resources• Wasted time• Adversarial relationships• Adversarial relationships

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The Simple (Defense) Solution

• Correct coding• Accurate (and adequate) documentation• Concurrent internal review

–Prevent “overcharges” (audit risk)–Prevent overcharges (audit risk)–Capture potential lost revenue

• Audit response –Medical records–Appeals

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Who Are the Auditors?What Are They Looking For?

• Coders• Nurses• MDs• Technical (computer) people• Technical (computer) people• Zebras at a water hole in Texas

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Hoofbeats in Texas?

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Think Like an Auditor

• “Close your eyes and see the patient”• Think like the attending physician• Read between the lines• Be suspicious• Recognize patterns• Recognize “red flags”• Inference• Decoding information

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How to Beat Them

• Understand case selection• Understand the contingency fee system• Accurate documentation• Good coding• Good coding• Think like them

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Focus on Documentation

• Accuracy• Consistency

– Doctors’ notes, consultants, nurses’ notes, lab, imaging

• LegibilityLegibility

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Accurate Coding

• ICD-9/ICD-10• Starts with accurate documentation

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Case Selection

• Algorithm based• Where are they hurting you the most?• Target the top issues

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What Can You Tell Me About This Picture?

• Sailing vessel • Under sail, not power• Mainsail reefed• Sloop rigged, jib and mainp gg , j• Length approx. 50 ft.• Close hauled (at 45-degree angle to the wind) on a

port tack• Wind speed about 35 mph (Beaufort force 7)• Sailing in a race/likely offshore• Angle of heel 40 degrees

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Documentation

• The good• The bad• The ugly

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Case Study 1

“PNEUMOTHORAX”• DRG 964 Multiple trauma w CC

• RW 1.7015

• 8052 Closed Fx thoracic vertebra• 8082 Closed Fx pubis• 80507 Closed Fx cervical vertebra• E 8120 MVC• 9221 Contusion chest wall• 8600 Traumatic pneumothorax

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Documentation

• PNEUMOTHORAX

• 86 YO F

• DRG 964 OTHER MULTIPLE TRAUMA W CC RW 1.7015

– Restrained driver in MVC 2 broken ribs NAD O2 sat 98%

– Fx vertebra, 6 ribs pubis

– Coded 8600 Traumatic pneumothorax

– CXR “No pneumothorax”

– CT Chest “tiny subtle dots of gas” “<1% pneumothorax”

• Deleted 8600 = DRG 552 MEDICAL BACK PROBLEMS

• W/O CC RW 0.7839

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“Tiny Bubbles”

• CXR “…no pneumothorax…”• CT chest “…tiny subtle dots of gas…< 1%.”

• Delete 8600 Traumatic pneumothorax• Delete 8600 Traumatic pneumothorax

• DRG 552 Medical back problems w/o CC

• RW 0.7839

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Case Study 2

• 38 YO male shot in the head at close range• Med flight to trauma center• Trached• Admitted• Admitted• Expired

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DRGTracheostomy for Non-ENT DX

• Principal procedure– Tracheostomy

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Find the Key ($80,000) Phrase

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Transport Form | EMS Run Sheet

See “Jaws clenched, surgical CRIC …

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transport to nearest trauma center”

Case Study 3

• Pneumonia• Culture + for pseudomonas

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Pseudomonas PneumoniaNOT

PNEUMONIA

78 YO M DRG 178 RESP INFECTIONS W CC RW1.5636

Sputum culture: pseudomonas code 4821 pseudomonas pneumonia

MD note: “Lobar pneumonia organism unspecified”486

Changed DRG to 194 SIMPLE PNEUMONIA W CC RW 1.0235

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Pseudomonas PneumoniaNOT (cont.)

• This patient did NOT have pseudomonas pneumonia (4281)

• The organisms seen on sputum gram stain were “oral Flora”/contaminants per the reportp p

• The physician’s DX is “Lobar Pneumonia Organism Unspecified”

• DRG 178 RW 1.5636 changed to DRG 194 RW 1.0235

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Case Study 4

• 102 YO female admitted for “respiratory distress”

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You Can’t Make This Up

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Coders

• Are your coders experienced?• RNs, LPNs, MDs?• Support them: training, education, feedback,

supervisionsupervision• Pay them well

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Documentation Specialists

• Are they experienced?• RNs, LPNs, MDs?• Support them: training, education, feedback,

supervisionsupervision• Pay them well

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Doctors

Need helpNeed help

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Coding Dichotomy

• Hospital coders are nonclinical people• Doctors are non-coding people• Doctors’ notes are often obscure/illegible• Clinical records are difficult to read and interpret• Clinical records are difficult to read and interpret• Clinicians/coders know what the medical

records should say

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How to Help

• Doctor liaison• Good dictation service• Scribe service• Record room facility• Record room facility• Templates, keywords, macros, customization• Creative writing• Perks, rewards, recognition – carrots vs. sticks

(MRH)• Education

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Creative Writing

• The young man looked pale. He was sweating profusely. Beads of perspiration ran down his forehead. The skin under his gown was dripping wet. I held his wrist to take the pulse and noted he felt cold and clammy. The strong odor of tobacco was on his breath.

• “I feel like my chest is being squeezed in a vise.”

• “How long have you been having this pain?”

• “It started when I got on the Mass Pike. About 2 hours ago.”

• “How bad is it on a scale of one to ten?”How bad is it on a scale of one to ten?

• “This is a ten doc.”

• I looked at his sallow face over the rim of my glasses. He had just driven the length of Massachusetts, over a hundred miles, with crushing chest pain.

• He was a 2-pack-a-day smoker but denied cocaine or other drugs. No personal history of heart disease, diabetes, or hypertension. He did not know his cholesterol level. His brother was diabetic and his father had died suddenly at the age of 49. As I listened to his heart I heard an extra beat and glanced at the cardiac monitor.

• The patient stiffened. His eyes rolled back in their sockets. Then he shook all over, in a brief seizure, and lost consciousness. He was in ventricular fibrillation. His heart had stopped.

From Chapter 1 of Everyday Crisis Management, by Mark L Friedman, MD, FACEP, FACP.

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OR

• This is a WDWN 25 YO male in NAD

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Because I’m the MD!

• Arrogance is NOT a substitute for good documentation

• Intentionally inaccurate documentation is FRAUD

• Zebras are rare in Texas

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Unlikely Events

• Incidental cholecystectomy in a septic patient

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Observation

• The “Observation Problem” circa 1985• The “Bad Old Days” before R/O MI• Sutton’s Law: “Go where the money is”

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Choose Observation

• SHORT-TERM (24–48h) treatment/assessment• Monitoring• Pending a decision to admit or discharge• Patient does not meet acute care IQ criteria• Unresponsive to 4h RX in ER• Unsafe to return home• CX ambulatory surgery• DX, RX, stabilization, discharge expected within 24h

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DRG Games

• CCs• MCCs• Documentation, criteria, templates

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Document Significance

• Who mentions it? – Attending, consultant, nurse, other– Was it worked up?– Was it treated?– Did it cost $/increase LOS?

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Acute Respiratory Failure

• Repeated ABGs?/monitoring?• Consultant?• Intubated?• RXed?• RXed?• ICU?

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Who’s Driving ?

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Who’s Driving the Boat?

• Medical director/MD• Consultants• Specialists• Coders• Coders• RNs

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How to Beat the RAC

• Know your adversary• What is their motivation?• What are they thinking?• What will they do next?• What will they do next?• Good documentation• Good coding• Credible appeals• Learn from experience/feedback loops

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References

• http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/recovery-audit-program/index.html?redirect=/rac

• 12/18/12 - RAC Program Myths [PDF, 271KB]• FY 2010 Report To Congress [PDF, 773KB]• Sept.1, 2011 Recovery Audit Program Final SOW [PDF, 291KB]• Recovery Auditors Contact Information-Dec2012 [PDF, 190KB]• Recovery Audit Program Slide Presentation [PDF, 39KB]• MM 6183 Limitation on Recoupment [PDF, 117KB]• The Medicare Appeals Process Brochure [PDF, 337KB]

• RAC website: www.cms.hhs.gov/RAC• RAC email: [email protected]• http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-

Program/Recent_Updates.html• http://www.aha.org/advocacy-issues/rac/ractrac.shtml AHA data

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Thank you. Questions?

Mark L. Friedman, MD, FACEP, FACPedoc02@gmail com 630 567 5991

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the workbook.

[email protected], 630-567-5991

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learning objectives how to beat the rac · how to beat the rac mark l. friedman, md, facep, facp...

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