Updated on: June 22, 2012

Preparing Records for RAC Scrutiny – The Role of the Physician Query

By
Original story posted on: December 28, 2009

gkelleyBy: George L. Kelley, MS, MBA

 

In preparing your facility for RAC reviews, our organization has supported and championed a data mining approach that will identify specific cases at risk for review by the RACs. Once these cases are identified, they need to be examined to determine:

 

  • Do they meet the criteria being tested (e.g. - Is the DRG assignment appropriate?),
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  • If they do not initially meet criteria, is there reasoning for the DRG assigned?
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  • Should the case be re-billed?

 

We have found that in many instances, documentation does exist to support the level billed. However, the information is not always immediately evident in the record, especially in regard to RAC review of cases for coding. One of the most useful tools to ensure that documentation supports the level billed can be the physician query.

 

The goal of this brief article is not to explain the query process or to instruct you on how to establish an effective process - there are many credible and detailed sources available to assist you. Our purpose is to dispel the controversy over using the query as a means of preparing for a RAC review.

 

One of the most effective strategies in preparing for RAC reviews is preparation - targeted, organized and thoughtful preparation. Targeted preparation includes a review of records that are likely RAC targets and subsequent actions to address those records (as noted above).

 

The Physician Query

 

A significant element of preparation is ensuring that the information in the medical record supports the level of care billed - or in the case of coding reviews, the DRG assigned. It is at this point that a strong and participatory physician query process can be beneficial to the provider.

 

Querying the physician post-discharge and post-billing generally would be for purposes of clarification. An easy and clear example to use would be for DRGs 573/574/575 (skin graft and/or debrid for skin ulcer or cellulitis). When the case originally was considered, all information pointed to the assignment of code 86.22. However, when performing a targeted review of cases likely to be reviewed by a RAC, it was found that although the documentation supports the DRG, documentation also states that the physician debrided with a sharp instrument. The physician did not state clearly the method of debridement, depth of debridement, instruments used and type of tissue removed or excised. This case would be a perfect candidate for a query: to request that the physician clarify the treatment provided to the patient in greater detail.

 

In many instances, provider personnel question the appropriateness of the post-bill query process. In fact, there have been instances in which provider representatives indicate that they feel this practice is not allowable. In truth, the fact of the matter is that post-bill queries are accepted practice in the industry and are utilized by many providers as a standard course of business to ensure complete and accurate billing and to assist hospitals in defending their positions as a result of an audit or review.

 

The keys in this process are to have a policy in place that directs staff toward the appropriate steps for your facility and to provide the guidance necessary to ensure a consistent approach to employing queries. An article published in the October 2008 Journal of AHIMA ("Managing an Effective Query Process" Journal of AHIMA 79, no.10 (October 2008): 83-88) supports the use of queries in this fashion and outlines a strategy for developing and managing an effective query process.

 

About the Author

 

George L. Kelley is the chief operating officer for CBIZ KA Consulting Services, LLC. He is a nationally recognized speaker noted for his expertise in discussing many topics that impact healthcare financial professionals including the Medicare outpatient prospective payment system, Recovery Audit Contractor (RAC) preparation and HIPPA readiness. Additionally, he assists clients in increasing net revenues by recovering managed care underpayments and recalibrating charging structures to ensure they receive the highest level of reimbursement.

Contact the Author: GKelley@CBIZ.com

 

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