Documentation is missing
The RAC will request medical records from a provider in order to determine if a payment error has occurred in those situations where incorrect reimbursement is suspected. The provider has 45 calendar days from the date of the request to provide the copies of the medical records. If all of the requested information is not provided, the RAC has no documentation to support the claim and the payments made to the provider. When this occurs, the RAC will issue a demand letter for recoupment from the provider of all or part of the reimbursement.
How does missing documentation occur?
1. The requested medical record cannot be located.
2. Key documents in the requested record are not included in the packet of copies sent to the RAC (e.g. a pathology report is missing). Missing reports may not have been forwarded by the ancillary department, may be in the "loose filing" stack, or may have been misfiled. In a hybrid record situation, the report may be part of a clinical system (e.g. laboratory information system or transcription system) that was not accessed by the person making the copies of the record and thus the report was overlooked.
3. The copying of the record was not done correctly. The wrong episode of care was copied or a page was missed or the backside of a two-sided document was not copied. Thus, the information needed to support the claim and reimbursement did not reach the RAC reviewers.
Documentation does not justify medical necessity
Physician documentation must clearly explain why the services provided to the patient (procedures, tests, therapies) are medically necessary. Medical necessity is supported by documentation of the diagnoses, signs, and symptoms that the patient has that require diagnostic or therapeutic intervention. Risk factors such as the patient's history or family history can also be useful as can a description of the chronic conditions or other factors affecting medical decisions.
In some instances, documentation is needed to explain why the services were provided in a particular location or at a certain level of care. For example, Medicare has designated that certain procedures should be provided in an outpatient setting. However, a specific patient may need the support of acute nursing care or have risk factors that require the type services that can only be provided in an inpatient setting. This patient treatment decision must be supported by documentation that indicates why this higher level of care is required for the patient (i.e. other conditions or risks, patient frailty, mental status, etc).
Another example involves the use of observation versus inpatient level of services. If documentation does not establish a Severity of Illness AND an Intensity of Service that justifies the need for inpatient care, the admission of the patient to the hospital may not appear to be necessary. The RAC may determine that the patient could have been treated in an observation unit or bed and issue a demand for the recoupment of funds representing the difference between an MS-DRG payment and payment for the Observation Services.
Documentation not supporting codes submitted on the claim
Diagnosis and procedure codes should only be assigned based on the documentation of the attending physician or surgeon in the medical record. This documentation must clearly describe any procedure performed (the approach, the scope or extent of the procedure, instruments and/or technology used, etc). Documentation to support the diagnosis codes needs to identify underlying conditions (e.g. hypertensive heart disease, diabetic neuropathy), causative agents or organisms (e.g. streptococcal pneumonia, alcoholic cirrhosis of liver), chronic or acute aspects, extent of disease (carcinoma of the breast with metastasis to cervical lymph nodes), extent and location of injury (closed, intertrochanteric fracture of the femur), etc. Other conditions, especially chronic diseases, which are not the specific reason for the services or admission, but impact the care given to the patient (intensity of care, medications, therapies, etc) must also be described.
When documentation is not clear and detailed, the RAC reviewers may determine that the codes submitted on the claim form are incorrect. The reviewer will recode the record and determine how payment is affected by the changes in codes. The provider will receive a demand letter for the difference in reimbursement determined by the new codes versus the original reimbursement.
It is clear from the experience of providers involved in the demonstration RAC program, that clinical documentation is necessary to support all reimbursement claims and to reduce or eliminate the risk that the RAC will determine that the original reimbursement is not appropriate.
Providers need to refocus an existing clinical documentation improvement program on RAC targets. If a provider does not currently have a clinical documentation improvement program, the provider needs to establish such a program as soon as possible.
About the Author
Cheryl Servais has more than 25 years of experience in Health Information Management. In her position at Precyse Solutions, Ms. Servais' responsibilities include planning, designing, implementing and maintaining corporate-wide compliance programs, policies and procedures, and updating them to accommodate changes in federal and other regulations. In addition, she oversees training and development programs related to ethics, compliance and patient privacy; develops and chairs compliance and privacy advisory committees at the Executive.
Cheryl E. Servais, MPH, RHIA, is Vice President, Compliance and Privacy Officer for Precyse Solutions