“While these devices can be accurate, compact, and convenient, it’s important to maintain a current [software] subscription to keep abreast of updates to the code sets, which occur sometimes as often as quarterly,” she says.
Pierce adds that coding tools should be double-checked against an audit tool. She has sometimes found discrepancies when auditing against an EMR product that assigns the E/M level.
Now, when I get questions from billers and coders, I try to answer them quickly. I don’t look upon them as the enemy, but rather as people who are helping me document appropriately, so I don’t get audited by Medicare. I think the way you view the coders and billers definitely affects your willingness to learn.— assistant site director, Hospitalists Management Group, Kenosha (Wis.)Amaka Nweke, MD, Medical Center
Attitude Adjustment
Coding experts emphasize that physicians need not worry about mastering coding manuals, but they should forge relationships with both their hospital’s billers and the coders for their practice.
Dr. Nweke took advantage of coding and billing workshops offered by her group, HMG, and through the seminars began to understand what a DRG meant not just for her hospital but for her own evaluations and the expansion of her HM group, too. “Now, when I get questions from billers and coders, I try to answer them quickly,” she says. “I don’t look upon them as the enemy, but rather as people who are helping me document appropriately, so I don’t get audited by Medicare. I think the way you view the coders and billers definitely affects your willingness to learn.”
Dr. Nweke also takes a broader view of her role as a hospitalist. “You are there to take care of patients and assist with transitioning them in and out of the hospital, but you’re also there to ensure that the hospital remains afloat financially,” she says. “Your documentation plays a huge role in that. We have a huge contribution to make.”
The patient gains, too, says Leon-Chisen, who explains that documentation should be as accurate as possible “because someone else—the patient’s primary physician—will be taking over care of that patient and needs to understand what happened in the hospital.”
“The bottom line,” Dr. Pinson says, “is that we need accurate documentation that can be correctly coded to reflect the true complexity of care and severity of illness. If we do that, good things will follow.” TH
Gretchen Henkel is a freelance writer based in California.
References
- 1997 Documentation Guidelines for Evaluation and Management Services. Centers for Medicare & Medicaid Services website. Available at: www.cms.gov/MLNProducts/Downloads/MASTER1.pdf. Accessed April 11, 2011.
- State of Hospital Medicine: 2010 Report Based on 2009 Data. Society of Hospital Medicine and Medical Group Management Association; Philadelphia and Englewood, Colo.; 2010.
- ICD-9-CM Official Coding Guidelines. CMS and National Center for Health Statistics; Washington, D.C.; 2008. Available at: www.ama-assn.org/resources/doc/cpt/icd9cm_coding_guidelines_08_09_full.pdf. Accessed April 10, 2011.
Take Proactive Approach to Recovery Audit Contractors
Leon-Chisen
Figure 1. Dollar Value of Automated and Complex Denials by RAC Region for Reporting Hospitals.**AHA analysis of survey data collected from 1,852 hospitals: 1,454 reporting activity, 398 reporting no activity through December 2010. Data were collected from general medical/surgical acute-care hospitals (including critical access hospitals and cancer hospitals), long-term acute care hospitals, inpatient rehabilitation hospitals, and inpatient psychiatric hospitals.
Source: American Hospital Association, RACTrac Survey, February 2011
The congressionally authorized Medicare Recovery Audit Contractor (RAC) program began with a three-year demonstration pilot project in 2005. In August 2010, the program expanded to the entire country. The RAC’s main objective is to identify improper Medicare payments, both overpayments and underpayments, to providers. CMS, which administrates Medicare and the RAC program, has agreements with contractors who are authorized to audit and review claims that are up to three years old.
According to Elizabeth Baskett, senior associate director of policy at the AHA, medical necessity review was a big focus of the RAC demonstration project and now is “under way in the permanent RAC program. We are bracing ourselves for a significant amount of denials.”
The AHA has created a free, Web-based survey called RAC Trac (www.aha.org/aha/issues/RAC/ractrac.html) to assess the nationwide impact the RAC program has on U.S. hospitals. In a report released Feb. 24, the RAC Trac survey shows that $82 million in denials were reported, more than double the dollar amount of denials reported in the third quarter of 2010 (see Figure 1, below). It also shows 57% of the more than 1,850 participating hospitals cited “medically unnecessary” as a reason for a denial of a claim.
Nearly 80% of the participating hospitals reported RAC activity in 2010, with general medical and surgical hospitals reporting the most activity. Fifty percent of reporting hospitals noted that their administrative burden—in the form of hiring consultants, copying medical records, hiring legal counsel, and the like—had increased as a result of RAC activity.
Most importantly, the report shows the average dollar value of automated denials was $399. But when a complex review—one involving a human review of requested records—was conducted, the average value of the denial was $5,281. Additionally, inpatient facilities were most likely to experience complex denials, which account for 90% of the value of denied claims.
Leong says RAC audits are just one area of “exposure to review for hospitals and providers. Other third-party payers, including individual commercial insurance companies,” she says, “also do routine post-payment review and recoupment, several years after payment.”—GH