Column: MLN Matters article offers insight for CDI role

The release of CMS Medlearn Matters articles Special Edition 1027,  Recovery Audit Contractor (RAC) Demonstration High-Risk Medical Necessity Vulnerabilities for Inpatient Hospitals, sheds some interesting light on the reality of where we may extend our efforts at clinical documentation improvement.

Let’s take a look at some of the issues and points raised by CMS in this article that poses potential RAC vulnerabilities to our facilities, examine a real case study that plays onto this risk, and discuss the real opportunity of CDI specialists to improve clinical documentation and mitigate these potential financial risks.

 

Consider several provisions identified in the article, the first being the 17 DRGs identified as presenting high risk of medical necessity vulnerabilities.

 

A large share of claims under the RAC demonstration project within these DRGs were denied because the documentation submitted did not support the services provided. The articles point out that in many instances the service/procedure was medically necessary but the services could have been performed in a less-intensive setting. Often, these denials occurred because the submitted documentation did not contain sufficient, accurate information to: