Updated on: June 22, 2012

RAC Denials and the Coder’s Quandary: Clinical Indicators Inconsistent with Documented Diagnoses

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Original story posted on: September 7, 2010

spencerCMany hospitals are receiving recovery audit contractor (RAC) denials based on physicians' documentation of major complications and/or co-morbidities (MCCs) and complications and/or co-morbidities (CCs).

The reason for the denials is that the documentation of the MCC and/or CC is inconsistent with the clinical picture or clinical indicators in the medical record.

 

Examples of the scenario include the following:

 

  • Sepsis was documented without a clinical indicator for it, and the short-stay length-of-stay is inconsistent with a "true" sepsis patient. Therefore, sepsis as a MCC may be denied.
  • Pneumonia was documented but there was no support, such as a negative chest x-ray, for the clinical diagnosis. This scenario may be denied as a MCC.
  • Acute renal failure was documented even though BUN and creatinine values were only minimally elevated. This is inconsistent with "true" clinical evidence of acute renal failure and may be denied as a MCC.
  • Acute respiratory failure is documented without clinical indicators and without exam findings for respiratory failure. This may be denied as a MCC.

 

The loss of each of these high-volume MCCs may reduce reimbursement by approximately $5,000 per case on medical MS-DRGs and $12,000 per case on a surgical MS-DRG.

 

Documentation Must Support Clinical Picture

Why are diagnoses being documented inconsistent with the patient's clinical picture or clinical indicators?  Many attribute this to zealous clinical- documentation-improvement efforts.

 

The 2011 proposed inpatient prospective payment system (IPPS) rule stated the following about the acute renal failure, unspecified (584.9) MCC: "Acute renal failure is widely used to capture degrees of renal failure that range from that which is caused by mild dehydration with only minor laboratory abnormalities all the way through severe renal failure that requires dialysis."

 

Furthermore, the proposed IPPS states that the attending physician "must simply document the presence of acute renal failure," and the coders should report the diagnosis code 584.9 MCC. In many cases, this is a single MCC, which increases reimbursement on the medical MS-DRG approximately $5,000. If this is a single MCC on a surgical MS-DRG, then this could increase reimbursement by $12,000.

 

In recent years, coders have confirmed an increased use of the term "acute renal failure" whereby in the past "acute renal insufficiency" was documented. A proposed rule commenter stated that "there has been an increased reporting of acute renal failure," which is primarily due to increased physician education by clinical documentation improvement programs.

 

Furthermore, data analysis performed by CMS determined that acute renal failure (584.9) does not utilize the same level of resources as other conditions on the MCC list. Based on the rationale and data analysis, CMS is proposing to change acute renal failure, unspecified (584.9) from a MCC to a CC. If this occurs, hospitals may experience reductions in Medicare payments anywhere from $1 million to $3.6 million dollars annually. CMS believes that this change will lead to more accurate payment, even if it does reduce some hospital payments.

 

Hospital Action Steps

 

A physician peer-review process must be established as an avenue for clinical documentation improvement specialists and coding staff to route cases in which MCC or CC diagnoses are documented (such as acute renal failure, acute respiratory failure, pneumonia, and others) but are inconsistent with the clinical picture, clinical indicators, and/or geometric mean length of stay.

 

Because documentation of a condition is present and a coder may not question the physician, a traditional retrospective query is not appropriate. These cases require a clinical-pertinence review.

 

Hospitals should develop policy and procedures surrounding this process.

 

About the Author


Carol Spencer, RHIA, CCS, CHDA is a senior healthcare consultant with Medical Learning, Inc. (MedLearn®) in St. Paul, Minn. MedLearn is a nationally recognized expert in healthcare compliance and reimbursement. Founded in 1991, MedLearn delivers actionable answers that equip healthcare organizations with coding, chargemaster, reimbursement management and RAC solutions.


Contact the Author


cspencer@medlearn.com

 

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